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

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COUNTY OF LOS ANGELES DEPARTMENT OF CHILDREN AND FAMILY SERVICES<br />

EMANCIPATION PREPARATION GOAL CONTRACT<br />

(To be completed by youth ages 14 <strong>and</strong> older)<br />

(CSW completes top section)<br />

This is a 6 month contract <strong>and</strong> represents the period <strong>of</strong> time beginning<br />

ending<br />

<strong>and</strong><br />

YOUTH’S NAME: AGE:<br />

DATE:<br />

CASE NAME: CASE #<br />

POTENTIAL EMANCIPATION DATE: NEXT COURT DATE:<br />

INSTRUCTIONS TO YOUTH: The purpose <strong>of</strong> this contract is to capture the goals you are agreeing to<br />

achieve over the next 6 months. It is a good organizing tool to help you stay focused <strong>and</strong> keep track <strong>of</strong><br />

your progress toward accomplishing each goal. Your CSW <strong>and</strong> Caregiver will also have copies <strong>of</strong> this<br />

contract <strong>and</strong> will help you monitor your success.<br />

My goal for the next 6 months is:<br />

ACTIVITY<br />

What will I do?<br />

DEADLINE<br />

When will I<br />

get it done?<br />

RESOURCES<br />

What people, places, <strong>and</strong> things are<br />

available to help me?<br />

DCFS 5205-B Page 1 <strong>of</strong> 1<br />

COMMENTS<br />

Signing this contract means we will all work to complete the steps necessary to help me meet my goals.<br />

My Signature:<br />

Date:<br />

Caregiver Signature:<br />

Date:<br />

CSW Signature:<br />

Date:<br />

EXHIBIT A-XI

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