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

SIGNATURES:
EXHIBIT A-V
MINOR:
THIS CASE PLAN HAS BEEN REVIEWED WITH ME. I AGREE TO ACTIVELY PARTICIPATE IN THE
ACTIVITIES AND WORK TOWARD THE GOALS DESCRIBED.
__________________________________________________ __________________
Minor’s Signature Date
PARENT/GUARDIAN:
THIS CASE PLAN HAS BEEN REVIEWED WITH ME. I AGREE TO ACTIVELY PARTICIPATE IN THE
ACTIVITIES AND WORK TOWARD THE GOALS DESCRIBED. I ALSO UNDERSTAND THAT
ADOPTIVE/COUNSELING SERVICES ARE AVAILABLE TO ME SHOULD I REQUEST THEM. I HAVE
RECEIVED A COPY OF THIS PLAN.
__________________________________________________ __________________
Parent/ Guardian Signature Date
No Parent Available.
Reason: __________________________________________________ Date: __________________
Parent Reviewed/Declined to Sign.
Reason: __________________________________________________ Date: __________________
Parent Refused to Participate in Case Plan/Declined to Sign.
Reason: __________________________________________________ Date: __________________
Case plan mailed to parent on (Date): _________________________________________________________
__________________________________________________ __________________
Deputy Probation Officer Date
__________________________________________________ __________________
Supervising Deputy Probation Officer Date
CAREGIVER/PROVIDER:
PLAN REVIEWED WITH CARE PROVIDER AND COPY OF PLAN GIVEN TO CARE PROVIDER ON ______
Date
__________________________________________________ __________________
Caregiver/Provider Signature Date
PROB 1385 (Rev. 07-03
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