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CMS-07-021/023 - Los Angeles County Department of Children and ...

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EXHIBIT A-V<br />

c) Between DPO <strong>and</strong> Minor Monthly Other (Justification for Exception to Monthly<br />

Contacts/Visits)_____________________________________________________________________<br />

__________________________________________________________________________________<br />

__________________________________________________________________________________<br />

d) Between DPO <strong>and</strong> Parents/Legal Guardian Monthly Other (Justification for Exception to<br />

Monthly Contacts/Visits) ______________________________________________________________<br />

__________________________________________________________________________________<br />

__________________________________________________________________________________<br />

e) Between DPO <strong>and</strong> Caregiver Monthly Other<br />

Substantial Distance from the Parent or Out-<strong>of</strong>-<strong>County</strong> Placement (Reason):<br />

Meets the Needs <strong>of</strong> Minor/Special Program Needs<br />

Local Placement Not Available<br />

Program Provides _____________________ Counseling.<br />

Out-<strong>of</strong>-State Placement-Reason (Complete only when court orders out-<strong>of</strong>-state placement.)<br />

(Minor must be referred to the MDT for assessment <strong>and</strong> screening prior to out-<strong>of</strong>-state placement. It must also be<br />

authorized <strong>and</strong> approved by ICPC before out-<strong>of</strong>-state placement can be made.):<br />

Meets the Needs <strong>of</strong> Minor/Special Program Needs<br />

MDT Recommends<br />

Local Placement Not Available<br />

Court Ordered<br />

Program Provides _____________________ Counseling<br />

ICPC 100A Approved by Receiving State.<br />

For Out-<strong>of</strong>-State Placement: Explain what in-state facilities or services were used or considered <strong>and</strong><br />

why they were not recommended. __________________________________________________________<br />

________________________________________________________________________________________<br />

Community Treatment Facility Placement:<br />

Meets the Needs <strong>of</strong> Minor/Special Program Needs<br />

MDT Recommends<br />

Court Ordered<br />

Program Provides ___________________________ Counseling.<br />

7. Objectives: (personal, legal, academic, vocational, emancipation preparation, psychological counseling,<br />

etc.) for each identified problem. Specify the activities <strong>and</strong> services to be provided <strong>and</strong> identify the<br />

individual or agency who is responsible to complete the activity or provide the service.<br />

Problem #1: ______________________________________________________________________________<br />

________________________________________________________________________________________<br />

Objectives/Activities: _______________________________________________________________________<br />

________________________________________________________________________________________<br />

Services to Be Provided: ____________________________________________________________________<br />

________________________________________________________________________________________<br />

Minor’s Responsibilities: ____________________________________________________________________<br />

________________________________________________________________________________________<br />

Parents’ Responsibilities: ___________________________________________________________________<br />

________________________________________________________________________________________<br />

Care Provider Responsibilities: _______________________________________________________________<br />

________________________________________________________________________________________<br />

4

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