Regional CPS Contracting Forms

Education and Training Voucher (ETV) Program

Title IV-E University-Training Services

FY16 Renewal Documents
Stipend Agreements

Client Services

General Documents

Form Number	Form Name	Form Purpose
2030	Budget for Purchase of Service Contracts	Budget pages for cost reimbursement contracts.
2030ins	(Instructions) Budget for Purchase of Service Contracts	Instructions for the "Budget pages for cost reimbursement contracts" form
2031	Signature Authority Designation	Contractors use the standard 2031, Additional Authorized Signature Designation page for multiple signatures when more than one person signs for different contract functions.
2057	Court Related Services Form	Contractors must print this out and take to DFPS court related service requests for signature and payment.
2128	24 Hour Awake Caregiver Supervision Plan- K-908-2128	Identity the 24 hour awake caregiver supervisor plan in a foster group home.
5500GEN	General Invoicing Procedures	Contractor uses as reference for services that do not have a designated invoicing procedure to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5615	Diagnostic Consultation Services Case Note	Contractors must print this out and take to DFPS Diagnostic Consultation requests for signature and payment.
5645V	Vendor Uniform Terms and Conditions	DFPS Uniform Terms and Conditions for Vendors. Required for each contract.
5622VRG	Regional Contracts Supplemental and Special Conditions	Supplemental and Special Conditions for CPS Regional Contracts for Vendors. Required for each contract.
PCS-102	Contracting Entity and List of Staff, Subcontractors, and Volunteers	Contractors must list the contracting entity, all service providers, and requested provider information on this form and submit it electronically to DFPS Contract Manager at contract inception and annually thereafter. Not to be used for Evaluation & Treatment, Substance Use Disorder (SUD) or Substance Abuse Services (SAS). For these services use PCS-102ET or PCS-102SUD by scrolling down to the appropriate table. Post Adoption Services must also use PCS-102PA.
PCS-107 (sample)	Subcontracting Review & Acceptance - sample form, do not fill out	For viewing only – This is a sample of the form DFPS Contract Staff use to document the review and acceptance of a Contractor’s Subcontracting Policies and Procedures.

Background Checks

Automated Background Check System (ABCS)

Form Number	Form Name	Form Purpose
2970c	Disclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect History For Applicants, Employees or Volunteers of DFPS Contractors and Subcontractors	Release of information regarding criminal history or DFPS abuse and neglect history.
2971c	Request for Background Check for Purchased Client Services Contractors	Application for requesting criminal history and DFPS abuse or neglect history.

Contract Monitoring Feedback

This survey may be completed by the Contractor after our DFPS onsite contract monitoring visit. Your feedback is essential to help us improve our services to you. We invite you to complete an anonymous survey at the following secure link: Contractor Satisfaction Survey. Thank you for your feedback.

Evaluation and Treatment (E&T)

Psychological and Treatment Services

Announcement: DFPS prefers providers with certification and training in Trauma-Informed Child Welfare Practice as well as knowledge and practice in evidence-based program interventions. These Provider Training Resources include website links so that you may become informed on the use of these practices. [download]

Form Number	Form Name	Form Purpose
K-903-2036	Evaluation & Treatment and BIPP Referral	This form is used by INV/FBSS/CVS to refer a client to Evaluation and Treatment (E&T) Services and/or Battering Intervention and Prevention Program (BIPP) Services.
2039sam	Psychological and Treatment Services Caseworker Satisfaction Survey Questionnaire - sample form, do not fill out	* For viewing only - This is a sample of the questionnaire the Caseworker will complete on each Contractor’s performance. It is provided solely for Contractors to view what they are being measured on regarding their performance.
2194	Translator/Interpreter Services Case Note and Certification	Contractor completes and submits a copy with billing and files a copy in the client record.
4502 / 4502s	Evaluation and Treatment Client Satisfaction Survey Questionnaire / Spanish	Contractor distributes questionnaire just prior to closing out services and collects data to report results in PMET or to Contract Performance semi-annually. Refer to Performance Measure Requirements in statement of work for details.
5500ET	Invoicing Procedures for Psychological and Treatment Services	Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5624 / 5624s	Client Orientation Acknowledgment / Spanish	Client acknowledgment of the information received from the Contractor describing the services offered, hours of operation, after-hours emergency contact, local community's behavioral health care crisis response information, and Client rights, programs rules, and privacy protections.
5627	Evaluation & Treatment Experience Summary	Contractor uses this form to summarize their professional experience working with crisis situations (adult or children), families with children between the ages of 3 and 5, treating victims of domestic violence, sexual abuse issues and administering evidence-based treatment.
5642	CPS Evaluation and Treatment Travel Log	This travel log is provided to you as a reference; this is not a required form. You may submit the required supporting documentation (contract section 2.13.3.8) in another format if you choose.
PCS-102ET	Contracting Entity and List of Staff, Subcontractors, and Volunteers - legal format	Contractors must list the contracting entity, all service providers, and requested provider information on this form and submit it electronically to DFPS Contract Manager at contract inception and annually thereafter. Note: This is a legal size document - please print on legal size paper.

Battering Intervention and Prevention Program (BIPP) Services

Form Number	Form Name	Form Purpose
5634	Domestic Violence Assessment Report	Battering Intervention Prevention Program (BIPP) Provider uses this template to determine Person Using Violence (PUV) appropriateness for BIPP program participation and to make recommendations for the possible need for referral to concurrent or prerequisite substance abuse, mental health, sex offender, or other applicable assessments or services.
5635	BIPP Coordination & Release of Information	The purpose of this form is to allow communication among the various providers who are serving this client. Providers may discuss progress, concerns, recommendations and any other information deemed useful to help stop the use of violence by this client or to protect the safety of any person, child or adult family or household member or professional intervener.
5636/5636s	BIPP Client Questionnaire / Spanish	Contractor administers this survey to clients as a pre-test and post-test at the beginning and the end of the BIPP intervention.
5637/5637s	BIPP Client Satisfaction Survey / Spanish	Contractor administers to BIPP client at the end of the intervention.

Chemical Dependency Services

Substance Use Disorder (SUD) Services (CDTF-Chemical Dependency Treatment Facility)

Form Number	Form Name	Form Purpose
2040	Substance Use Services	Use this form to provide information about the client's contact with the substance use services screener or provider.
2063/2063s	Release of Confidential Information / Spanish	Client completes this form (with caseworker's assistance, if necessary) for voluntary release of confidential information for the purposes of substance abuse services, counseling, or referrals.

Substance Abuse (SAS) Services (LCDC-Licensed Chemical Dependency Counselor)

Form Number	Form Name	Form Purpose
2040SAS	Substance Use Services	Use this form to provide information about the client's contact with the substance use services screener or provider.

Both: Substance Use Disorder (SUD) / Substance Abuse (SAS) Services

Form Number	Form Name	Form Purpose
4503	Substance Abuse Services Client Satisfaction Survey	Contractor distributes questionnaire just prior to closing out services and collects data to report results in PMET or to Contract Performance semi-annually. Refer to Performance Measure Requirements in statement of work for details.
4508sam	Substance Use Disorder Services Caseworker Satisfaction Survey Questionnaire	* For viewing only - This is a sample of the questionnaire the Caseworker will complete on each Contractor’s performance. It is provided solely for Contractors to view what they are being measured on regarding their performance. This questionnaire is used for both SUD and SAS services.
5500CHEM	Invoicing Procedures for Chemical Dependency	Contractor uses as reference with SUD and SAS Services to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
PCS-102SUD	Contracting Entity and List of Staff, Subcontractors, and Volunteers – Substance Abuse Services - legal format	Contractors must list the contracting entity, all service providers, and requested provider information on this form and submit it electronically to DFPS Contract Manager at contract inception and annually thereafter. Note: This is a legal size document - please print on legal size paper. To be used for all chemical dependency services.
SUDS Survey	Substance Use Disorder Services (SUDS) Caseworker Satisfaction Survey Questionnaire - sample form, do not fill out	* For viewing only - This is a sample of the questionnaire the Caseworker will complete on each Contractor’s performance. It is provided solely for Contractors to view what they are being measured on regarding their performance. This questionnaire is used for both SUD and SAS services.

Psychiatric Services

Form Number	Form Name	Form Purpose
Evaluation and Treatment Psychiatric Services Caseworker Satisfaction Survey Questionnaire - sample form, do not fill out	* For viewing only - This is a sample of the questionnaire the Caseworker will complete on each Contractor’s performance. It is provided solely for Contractors to view what they are being measured on regarding their performance.

Supervised Visitation Services

Form Number	Form Name	Form Purpose
3100	Authorization to Release Information	Contractor ensures this document is completed and signed by client and returns form to caseworker with completed assessment.
3101	Referral for Supervised Visit Services	Referral Form provided to Contractor by CPS Program.
3102A	Parent Caretaker Observation Form / Checklist	Visitation worker (Observer) completes this form during the supervised visit.
3103A / 3103As	Supervised Visitation Expectations for Caregivers and Adult Participant(s) / Spanish	Visitation worker (Observer) reviews or reads these expectations to the Caregivers and all approved Adult Participants at the time of the first supervised visit. Visitation worker must have them sign form and provide them with a copy prior to the first visit.
3104a	Sign In Log	Visitation worker (Observer) ensures all who are present sign this log.
3113	Sibling Relationship Checklist	Visitation worker (Observer) completes this form during the supervised visit.
3114	Supervised Visitation Satisfaction Survey Questionnaire	Contractor provides form to participants to complete upon conclusion of the last visit authorized by each 2054. Refer to Performance Measure Requirements in statement of work for details.
3115	Referral for DFPS Supervision (CWOP)	Caseworker provides contact information for referral to Contractor who will provide DFPS supervision services until a placement is secured.
4505sam	Supervised Visitation Caseworker Satisfaction Survey - sample form, do not fill out	* For viewing only - This is a sample of the questionnaire the Caseworker will complete on each Contractor’s performance. It is provided solely for Contractors to view what they are being measured on regarding their performance.

Hospital Sitting Services

Form Number	Form Name	Form Purpose
5612	Referral for Hospital Sitting Services	Referral Form provided to Contractor by CPS Program.
5613	Sign-In Log for Hospital Sitting Services	Hospital Sitter ensures all who are present sign this log.

Family Group Decision Making Conference Services

Family Group Conferences (FGC)

Form Number	Form Name	Form Purpose
0621 / 0621s	FTM/FGC Conditions of Participation & Privacy Agreement / Spanish	Contractor ensures conference participants read and sign prior to conference to ensure privacy of participants.
0622 / 0622s	Family Team Meeting/Family Group Conference Agreement to Participate / Spanish	Contractor ensures parents read and sign this form prior to conference.
0625	Family Group Decision-Making Satisfaction Survey Questionnaire	Contractor provides form to participants to complete upon conclusion of the planning conference.
0629	FGDM Conference Agenda	The agenda is used by conference facilitator as guidance to follow the key points to be discussed for the planning needs of the family.
0630	Family Group Conference Plan	This electronic form (template) is used by conference staff to document the key points discussed in the meeting and the plan made at the FGC.
0631	Withdrawn Conference	Contractor may withdraw a conference based on family refusal or cancellation and must complete this form for payment.

Permanency Conferences (PC)

Form Number	Form Name	Form Purpose
0625PC	Permanency Conference Satisfaction Survey Questionnaire	Contractor provides form to participants to complete upon conclusion of the planning conference (PC).
0628	Permanency Conference Plan	This form is used by Contractor to document the key points discussed in the meeting and the plan made at the Permanency Conference (PC). Prior to beginning the Permanency Conference, participants sign and agree to Section B: the Conditions of Participation /Privacy Agreement.
0628a	Permanency Conference - Additional Child	This form is used by conference staff during a Permanency Conference with families that have multiple children.
0628ins	Permanency Conference Instructions	This form provides guidance to staff responsible for completing Form 0628, Permanency Conference Plan (PC Plan).
0628s	Plan de Conferencia de Permanencia	El personal de las FGDM usa esta forma para documentar los puntos clave que se platiquen en la reunión y el plan que se formule en la Conferencia sobre la Colocación Permanente (PC).
2500	Transition Plan	This form is used by conference staff during a Permanency Conference with Youth.

Home Study and Report Services

All Home Study and Report Types

Form Number	Form Name	Form Purpose
2006 / 2006s	Applicant Satisfaction Survey Questionnaire / Spanish	Contractor provides form to applicants to complete upon conclusion of the assessment.
5500	Invoicing Procedures for Assessment Services	Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5519	Summary of Qualifications	Contractor completes form on all key personnel and Child Placement Management (CPM) Staff and submits with the PCS-102, Contracting Entity and List of Staff, Subcontractors, and Volunteers.
5520	Withdrawal Report	Contractor submits form and applicable Contact Log to support the reimbursement percentage of withdrawn assessment.

Kinship Caregiver Home Assessment Services

Form Number	Form Name	Form Purpose
0398 / 0398s	Kinship Profile Questionnaire / Spanish	Contractor may use questionnaire. Contractor may provide questionnaire to the caregiver to complete. If used, completed questionnaire is returned to CPS with completed assessment.
0399	Kinship Release of Information and Acknowledgement	Contractor ensures this document is completed and signed by client and returns form to caseworker with completed assessment.
0399s	Ceción de Información y Reconocimiento de Parentesco	Contractor ensures this document is completed and signed by client and returns form to caseworker with completed assessment.
2049	Risk Assessment Form	Contractor completes this form and uses it to complete the Safety section of the Kinship Caregiver Home Assessment Template.
2700KIN	Routing and Approval Form (sample form, do not fill out)	For viewing only - This is a sample of the Routing and Approval form the Contractor will receive when being asked to complete a home assessment. The Contractor receives this form from CPS with sections 1-3 completed at the time of referral. Contractor refers to Invoicing Procedures for instructions on how to complete this form.
6581	Request for Kinship Home Assessment or Services	Referral Form provided to Contractor by CPS Program.
6588	Kinship Caregiver Home Assessment Template	Contractor uses template to complete the assessment (includes Intestate Compact on the Placement of Children - ICPC).
ICPC Regulation Number 2	ICPC Regulation Number 2	Case manager statement provided to Contractor by CPS Program
Kinship Manual	Kinship Manual / Spanish	Contractor provides manual to Kinship client. This manual is available in English and Spanish.

Health, Social, Educational and Genetic History (HSEGH) *

* also referred to as an Adoption Readiness Study

Form Number	Form Name	Form Purpose
2649	Health, Social, Educational, and Genetic History (HSEGH) Form	Contractor uses guide to complete the HSEGH Report.
2649i	HSEGH Report Instructions for Contractor	Contractor uses instructions to complete the HSEGH Report.
2659	Health, Social, Education, and Genetic History (HSEGH) Additional Page	Contractor uses this form when there is not enough space in Form 2649.
2700HSEGH	Routing and Approval Form - sample form, do not fill out	* For viewing only - This is a sample of the Routing and Approval form the Contractor will receive when being asked to complete a home assessment. The Contractor receives this form from CPS with sections 1-3 completed at the time of referral. Contractor refers to Invoicing Procedures for instructions on how to complete this form.

Foster/Adoptive (FAD) Home Screening Services

Form Number	Form Name	Form Purpose
2178	Home Screening Referral Form	Referral Form provided to Contractor by CPS Program
2191	Foster/Adoptive Home Screening	Contractor uses template to complete the Foster/Adoptive Home Screening.
2191ins	Instructions for Foster/Adoptive Home Screening	Contractor uses instructions to complete the Foster/Adoptive Home Screening.
2193	Foster/Adoptive Home Screening with Kinship Guide	Contractor uses this guide for comparison and location of information in previously completed Kinship Caregiver Home Assessment to complete this Foster/Adoptive Home Screening with Kinship.
2700FAD	Foster/Adopt Routing and Approval - sample form, do not fill out	* For viewing only - This is a sample of the Routing and Approval form the Contractor will receive when being asked to complete a home screening, report, or assessment. The Contractor receives this form from CPS with sections 1-3 completed at the time of referral. Contractor refers to Invoicing Procedures for instructions on how to complete this form.

Interstate Compact for the Placement of Children (ICPC) - Courtesy Supervision

Form Number	Form Name	Form Purpose
0104	ICPC Supervision Report	In-State Contractor must complete this document for Courtesy Supervision Services provided to the family and submit every 30-90 days as applicable.
2049	Risk Assessment	In-State Contractor completes upon request by DFPS, when one has not been provided.
5650	Contractor Visitation Log	Out-of-State Contractor must complete on a monthly basis and submit to DFPS with invoice. Form is used to document activities and billable hours in support of monthly invoice submitted to DFPS.

Adoption Services (In- and Out-of-State)

Form Number	Form Name	Form Purpose
2085-B	Designation of Medical Consenter for Non DFPS Employee	Contractor must use this form for the adoptive child in order to identify medical consenter and back up medical consenter.
2226	Adoptive Placement Agreement	Contractor uses this form at the placement of the child(ren) in the prospective adoptive home.
2238	Non-DFPS Adoptive Home Registration	Contractor must complete this form and submit to DFPS to provide demographic information, updates, and to close adoptive homes listed with IMPACT (Information Management Protecting Adults and Children in Texas automation system). Includes instructions for form.
5500ADO	Invoicing Procedures for Adoption Services	Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
Adoption Plan	Adoption Plan	Contractor must complete for each child.
Checklist for Adoption	Checklist for Adoption Services Payment	Contractor uses when submitting information to receive payment for services rendered.
Checklist for Post-Placement	Checklist for Post-Placement Adoption Services Payment	Contractor uses when submitting information to receive payment for services rendered.
Special Needs Adoption Training	Special Needs Adoption Training Curricula Resources for Contractors	Contractors use for assistance to develop their own curricula to meet training requirements outlined in the contract Statement of Work.

Post-Adoption Services

Form Number	Form Name	Form Purpose
2054	Service Authorization	Contractor completes this form to identify appropriate services to be provided to post adoption children and families.
5500PA	Post Adoption Invoicing Procedures	Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5517	Post Adoption - Purchased Client Services Monthly Expenditures Report	Contractor completes this form monthly and submits it with billing invoice.
5600	Post Adoption Service Plan	Contractors complete this Service Plan to assess the adopted child and adoptive family needs and determine appropriate services.
5602 / 5602S	Post Adoption Services Questionnaire / Spanish	Contractor provides questionnaire in April to all clients who have received services during the current year.
PCS-102PA	Contracting Entity and List of Staff, Subcontractors, and Volunteers - Post Adoption	Contractors must list the contracting entity, all service providers, and requested provider information on this form and submit it electronically to DFPS Contract Manager. Refer to Instructions tab for additional information.
PCS-108	Post Adopt Monthly Activity Report & Fiscal Year Summary	Contractors complete this report to keep DFPS informed on families and children served during the previous month and submit report monthly to the DFPS Contract Manager.

Post Permanency Services

Form Number	Form Name	Form Purpose
2054	Service Authorization	Referral Form provided to Contractor by CPS Program.
5500PP	Post Permanency Invoicing Procedures	Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5517PP	Purchased Client Services Monthly Expenditures Report	Contractor completes this form monthly and submits it with billing invoice.
5550	Post-Permanency Services Questionnaire English \| Spanish	Contractor provides this questionnaire to all families who received Post-Permanency services within the current contract year
5600	Post Permanency Service Plan	Contractors complete this Service Plan to assess the adopted child and adoptive family needs and determine appropriate services.
PCS-102PP	Contracting Entity and List of Staff, Subcontractors, and Volunteers - Post Permanency	Contractors must list the contracting entity, all service providers, and requested provider information on this form and submit it electronically to DFPS Contract Manager at contract inception and annually thereafter. Note: This is a legal size document - please print on legal size paper.
PCS-110	Post Permanency Monthly Activity Report & Fiscal Year Summary	Contractors complete this report to keep DFPS informed on families and children served during the previous month and submit report monthly to the DFPS Contract Manager.

Community and Parent Group Services

Form Number	Form Name	Form Purpose
Roberts Rules of Order

Regional Child Welfare Board/Councils (CWBC)

Form Number	Form Name	Form Purpose
5603	Business Plan	Optional template for business plan that will be completed annually by councils. Complete only the information that is applicable to the activities of the regional council.
5604	Meeting Agendas/Minutes	Optional template for agenda/minutes is provided as a tool for guidance on what types of information to cover during meetings. Councils may use their council Meeting Agenda/Minutes when already available.
5609	Performance Measure Data Report	Required - The purpose of the Child Welfare Board/Council Contract Performance Measures Data Reporting form is to collect Performance Measures Data.

Foster Parent Associations (FPA)

Form Number	Form Name	Form Purpose
5605	Meeting Agenda/Minutes	Optional template for minutes is provided as a tool for guidance on what types of information to cover during meetings. Associations may use their own Meeting Agenda/Minutes when already available.
5606	Progress Report	Optional template for progress report may be completed when Associations meet. Complete only the information that is applicable to the activities of the Association.
5607	Child Care Reimbursement Form	Submit with billing for reimbursement of child care during meetings.
5608	Performance Measure Data Report	Required - The purpose of the Texas Foster Parent Associations Contract Performance Measures Data Reporting form is to collect Performance Measures Data.

Preparation for Adult Living (PAL) Services

Training for the Casey Life Skills Assessment (CLSA) can be found on the DFPS Contractor Training and Support page.

Life Skills Training and Assessment

Form Number	Form Name	Form Purpose
5500LST	Invoicing Procedures for PAL Life Skills Training	Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5500TFS	Invoicing Procedures for PAL Transitional and Financial Support Services	Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5501	PAL Referral Form	DFPS PAL staff provides form to Contractor for each youth.
5502	Individual Monthly Progress Report	Contractor submits this form monthly except in September and March, when this form is required weekly.
5503	Independent Study Guide Caregiver Report	Contractor obtains this form signed and completed from Youth.
5504	Knowledge Assessment	Contractor administers this form one (1) time at completion of all 6 core elements of Life Skills Training.
5506	Knowledge Assessment Feedback to Youth	Contractor completes this form one (1) time at completion of all 6 core elements of Life Skills Training and provides it to the Youth.
5507	DFPS Approval of Qualifications and Requirements	Contractor submits form to DFPS CPS Contract Manager for review of staff and volunteers.
5508	Training Class Schedule	Contractor must submit a proposed schedule for each series of training sessions for DFPS PAL staff review and approval.
5509	Contractor Monthly Report	Contractor submits this form to DFPS PAL staff on a monthly basis.
5510	Participant Evaluation	Contractor conducts an evaluation and Youth completes this form at conclusion of training series.
5510sam	Participant Evaluation Sample	Contractor may offer sample copy to Youth early in the process to any Youth who wants a copy for information purposes.
5518PALLST	PAL Life Skills Training – Contractor Billing Report	Contractor completes this form monthly and submits it to the contract manager with billing. This form includes the new service code 18L.
5518PALTFS (HR133)	PAL Transition and Financial Support Services – Contractor Billing Report	Contractor completes this form monthly and submits it to the contract manager with billing. This form includes the new service codes (20B and 20C) and the HR133 expenses.

Transition and Financial Support Services

Form Number	Form Name	Form Purpose
5511	Contractor Monthly Report	Contractor must provide to DFPS PAL staff on a monthly basis. Due date time frames are listed in Statement of Work (SOW).
5512es	Authorization to Release Information	Contractor obtains this form signed and completed from Youth (includes English and Spanish).
5513	PAL Transition Report	Contractor must complete this report during delivery of the Transitional Living Allowance.
5514	Individual Monthly Progress Report	Contractor submits this form monthly except in September and March, when this form is required weekly.
5514a	Supplement to the Individual Monthly Progress Report	Contractor uses this form when additional space is needed to record additional contact information. Contractor submits this form with same time frames as 5614 Individual Monthly Progress Report.
5515i	Individual Monthly Progress Report Descriptions	Contractor refers to these descriptions when filling out the Individual Monthly Progress Report.
5516	Initial or Review Child’s Plan of Service Signature Sheet	Contractor must complete with Youth at each face to face meeting.
5518CM	PAL Monthly Expenditure Report - Case Management	Contractor completes this form monthly and submits it to contract manager with billing.
5518CM (HR133)	PAL Monthly Expenditure Report - Case Management (HR133)	Contractor completes this form monthly to identify the expenses related to HR133.
5525	Pre-Transitional Monthly Progress Report	Contractor documents contacts and services with individual youth or young adults in the pre-transition stage.
5526	Post-Transitional Monthly Progress Report	Contractor documents contacts and services with individual clients in the post-transition stage.
5617 / 5617s	PAL Transition Support Services Participant Evaluation / Spanish	Contractor provides form to participants to complete annually during month of March. Refer to Performance Measure Requirements in statement of work for details.
5619	Transition and Financial Support Services Referral	DFPS PAL staff provides this form to the Contractor for each youth who needs services.
CPS Handbook	Child Protective Services Handbook	After Care Room and Board Services: Go to the CPS Handbook (Appendix 10200) for the current requirements and policies regarding to PAL Aftercare Services

Both: Life Skills Training and Assessment / Transition and Financial Support Services

Form Number	Form Name	Form Purpose
2500	Transition Plan	Contractor must refer to this form to assist Youth identify action items during each core element of the training.
5006i	PAL Contractor Guide	Contractor uses guide to follow the Budget Summary provided monthly by contract staff.
5618	Contract Performance Measures Data Reporting Form	USED BY HARRIS COUNTY ONLY: Contractor uses this form to report both PAL Life Skills and Case Management performance measure data to DFPS Contract Performance

PAL Teen Conference

Form Number	Form Name	Form Purpose
5522	PAL Teen Conference Adult Evaluation	Contractor ensures this evaluation document is completed by the adult participant(s) and compiled data from these evaluations is used to meet reporting requirements. Refer to the Performance Measure Requirements for detailed instructions.
5523	PAL Teen Conference Youth Evaluation	Contractor ensures this evaluation document is completed by the youth participant(s) and compiled data from these evaluations is used to meet reporting requirements. Refer to the Performance Measure Requirements for detailed instructions.

Education and Training Voucher (ETV) Program

Form Number	Form Name	Form Purpose
5521	Consent for Release of Information for the Education and Training Voucher (ETV) Program	The form gives consent from the client to the Contractor to set up payments to vendors. The Contractor ensures this document is completed and signed by the client and is returned by the client to the Contractor staff.

Title IV-E University-Training Services

The Texas Department of Family and Protective Services (DFPS) has a staff development and training program that supports the goals and objectives in the Child and Family Services state plan for Title IV-E training. The Title IV-E Training Program targets public colleges and universities in Texas that have accredited Social Work Programs.

If you are interested in participating in this training and education program, please download this flyer.

You may also contact us at the CPS University email and someone who can answer your questions and provide more information will reply promptly.

Renewal Documents

Form Number	Form Name	Form Purpose
9310	Budget for Title IV-E University Training Contracts	Contractors use this workbook which contains multiple worksheets to complete the budget when the budget is Indirect Cost Rate (IDC) and based on Modified Total Direct Cost (MTDC). This document also contains instructions for guidance in developing the budget.
9321	Title IV-E Training Expense Documentation	Contractors complete to document training.
Attachment B	Plan of Operation	Contractors use to complete their Plan of Operation document which must be consistent with the budget and budget narrative.

Stipend Agreements

Form Number	Form Name	Form Purpose
2282EMPL MSW/BSW2	Employee Agreement (MSW/BSW2)	Agreement for BSW/MSW students (part-time or full-time), beginning the Stipend Program in Fall 2013 and thereafter.
2282STUDNTMSW	Employee Agreement (MSW)	Agreement for MSW students (part-time or full-time), beginning the Stipend Program in Fall 2013 and thereafter.
2282STUDNTBSW1	Employee Agreement (BSW1)	Agreement for BSW students beginning the Stipend Program in Fall 2013 and thereafter.
7039	Stipend Student Information Excel Spreadsheet	Contractors use this form to provide student information that is transferred into the Stipend Agreements.