Please Complete One Form Per Child

Tennessee Department of Children’s Services REQUEST FOR PERMANENCY GOAL OF PLANNED PERMANENT LIVING ARRANGEMENT

Please complete one form per child. All fields must be completed prior to submission to Central Office.

TFACTS ID# Person ID# Child’s Name: Date of Birth: Date Region: Date of Date Custody: Adjudication: Case Manager: Team Leader: Current Placement: How long has the child/youth been in this placement? Enter the date that this goal was discussed and Date recommended by the Child and Family Team

(Check One of the following): 1st Request Additional Request

Reason for Additional Request: (Check one): To change PPLA from a concurrent goal to the sole goal for the child To request an annual review of the goal of PPLA To review PPLA due to a change in the child’s placement caregiver

Planned Permanent Living Arrangement should be used as a goal only in certain, rare circumstances for youth who are at least 16 years old. In order for PPLA to be considered, at least one of the following must be true: (Check appropriate box/boxes.) The youth’s foster family is a relative or kinship foster home. Due to family circumstances, the foster parent(s) do not wish to adopt or pursue permanent guardianship, but do need the financial support of the board payment to continue to provide care. The youth is16 years or older, has received adoption counseling, and does not wish to be adopted. The current foster family has committed to care for this youth long-term. All other permanency goals have been actively pursued and have not led to permanency. The Child and Family Team has explored all of the other permanency options and recommended PPLA as a concurrent or sole goal for this youth.

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval. Distribution: Child’s case File, Regional Office RDA 2982 CS- 0681 Page 1 Rev. 07/15 Planned Permanent Living Arrangement cannot be used for any child under the age of 16 unless there are very special circumstances. In order for PPLA to be considered for a child younger than 16, at least one of the following must be true: (check appropriate box/boxes)

The child’s foster family is a relative. Due to family circumstances, the relative does not wish to adopt or pursue permanent guardianship but does need the financial support of the board payment. Extraordinary circumstances exist that warrant an exception to the requirements for PPLA.

Please explain what efforts have been made to achieve permanency for this child/youth through the other permanency options. 1. Reunification:

2. Exit Custody to Relative/ Permanent Guardianship:

3. Adoption:

3. Permanent Guardianship:

Please explain, in detail, the long-term plans for this child/youth. What are the plans for the child/youth’s transition to adulthood including education, employment, independent living, relational permanency, etc?

Will this child/youth’s placement support him or her to the age of majority and beyond?

Who are the other adults with a significant bond or relationship to the child/youth who can help support the transition to adulthood?

If this child/youth is placed with a relative, please explain why adoption or exiting custody with the Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval. Distribution: Child’s case File, Regional Office RDA 2982 CS- 0681 Page 2 Rev. 07/15 relative/permanent guardianship is not an appropriate goal.

When was a comprehensive case review (archaeological dig) completed on this child/youth? What was the result?

Please list the members of the child and family team making this recommendation and their contact numbers. Be sure to include the youth, the foster parent(s) and any other team members who can assist the reviewer in assessing this request. Name Relationship to the child Telephone Number(s) Child/Youth Foster Parent

Requests cannot be evaluated without attaching the Child and Family Team Meeting form. Please attach any additional documentation you have to support your request such as: court reports, evaluation results, letters from the child or foster parents, etc.

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval. Distribution: Child’s case File, Regional Office RDA 2982 CS- 0681 Page 3 Rev. 07/15 SIGNATURE AND APPROVAL PAGE

I believe that this child/youth meets the criteria for consideration of PPLA as a permanency goal. I understand that approval of PPLA as a permanency goal does not imply that no further permanency work will be done on behalf of this child/youth. I will continue to work towards other permanency goals, should they become viable alternatives.

I am committed to ensuring that this child/youth has meaningful, permanent connections to caring adults as he or she transitions to adulthood.

Case Manager: Date:

Team Leader: Date:

Team Coordinator: Date:

Regional Administrator: Date:

This request must be reviewed and approved by the Regional Administrator or his/her designee prior to submission to Central Office for approval. When approved by Regional Administrator, please forward this form and any other documents supporting your request to the Office of Permanency Planning.

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval. Distribution: Child’s case File, Regional Office RDA 2982 CS- 0681 Page 4 Rev. 07/15