ࡱ> IKH+ "bjbj .@DhDh DDDDDXXX8,LX(((((((($w*--,(D,(DDA(^DD((2&';A&'W(0(&-)|- '-D'<,(,(L(-X : DEPARTMENT OF HEALTH & HUMAN SERVICES V9 AGREEMENT VOLUNTARY EXTENDED CARE/CASE PLAN PartI Contact Information: Youth: __________________________ Address: ______________________________ Ph/Cell No: ______________________________ Email:__________________________ Caseworker: _____________________ Address: ______________________________ Phone No: ______________________________ Email:___________________________ Supervisor: _____________________ Address: _______________________________ Phone No: ______________________________ Email:___________________________ Program Administrator: ___________________Address: _______________________ Phone No: ______________________________ Email:___________________________ Youth Transition Worker: _________________Address: _______________________ Phone No: ______________________________ Email:___________________________ PartII General Terms (Apply to all V9 Agreements): I understand the Department of Health and Human Services (the Department) or the youth may renegotiate, suspend, or terminate this voluntary agreement by providing written notice. There is a 90 day period within which to renegotiate this agreement under terms that are mutually agreed upon between the youth and Department. I understand that I have the right to request a meeting with my caseworker and their supervisor at any time to renegotiate the terms of my Agreement. I understand that this agreement may be modified as circumstances, needs and abilities change, as long as the Department and I agree to the modifications. I understand that in order to participate in this program, I must sign releases of information to allow continued communication between the Department and other professionals providing services to me, including caregivers, service providers, and educational providers. I understand that this Agreement may be suspended if I engage in violent or serious criminal behavior, consistently fail to follow the terms of this agreement, or fail to remain in good academic standing. 5. I understand that the Department will not: Assume responsibility for any damages incurred by me after age 18. Sign "releases of information" forms for me beginning at age 18. Assume responsibility for any contracts I make beginning at age 18. Co-sign leases or contracts with me beginning at age 18. Provide legal counsel for me after age 18. PartIII Transition Planning: Permanency Goal(s): Need(s): Life Long Connections/Mentors: Goal(s): Need(s): Housing: Goal(s): Need(s): Health Insurance/Health Care Proxy: Goal(s): Need(s): Education: Goal(s): Need(s): Employment and Work Support: Goal(s): Need(s): Physical/Sexual/Mental Health: Goal(s): Need(s): Transportation: Goal(s): Need(s): Financial Education: Goal(s): Need(s): Vital Documents: Goal(s): Need(s): Life Skills: Goal(s): Need(s): Support Services: Goal(s): Need(s): Other(s): ______________________________ Goal(s): Need(s): PartIV Terms that are specific to (name of youth) ___________________________: 1. This voluntary agreement is for the purpose of: I agree to participate in the following services unless or until there is consensus between my caseworker, the service provider and myself that they have been successfully completed or are no longer necessary: I agree to participate in the following Education Plan (provide specific details, including hours of attendance required, of education programming): I agree to the following conditions of employment (include minimum number of hours of employment required): I agree to apply for fb88Care at age 18 and reapply as required to maintain coverage. I agree to the following additional conditions of this agreement: Part V The Department of Health and Human Services agrees to provide the following services as long as this agreement is in effect (note that agreement cannot extend beyond 21st birthday): The Department agrees to provide negotiated financial support based on my budget and available funds, which may include: rent (including decisions regarding roommates), room and board, foster care board payments, education costs, clothing allowances, and any other specified financial assistance. Monthly financial support in the amount of: _$_______ will be provided. The Department agrees to assist me to apply for support benefits, such as fb88Care, Food Stamps, TANF, Social Security, etc. The Department will assign a caseworker to provide the following services to me: Partner with me to help me achieve the goals of my Transition Plan (Part III); Advocate with me or on my behalf when needed; Direct access to my caseworker for advice, consultation, guidance and support; Feedback on my progress at reaching goals I have identified with my caseworker; Referrals for services which can help me to achieve goals I have identified; Support and assist me when I am struggling with difficult challenges or crises in my life; Other services as agreed to by caseworker and youth (specify): I ACCEPT THE TERMS OF THIS V9 AGREEMENT ___. Youth will be given a copy of this V9 Agreement I DECLINE THE OFFER OF A V9 AGREEMENT AT THIS TIME ____. Youth will be given a copy of this V9 Agreement with contact information completed in Part 1. Youth will be notified that they have the right to change their mind and request a V9 Agreement from the Department until the age of 21. Signature of Youth _______________________________ Date _________ Signature ofCaseworker __________________________ Date _________ Signature ofSupervisor ___________________________ Date _________ Optional Consent I do ___ do not ___ agree to allow DHHS to provide my contact information to Muskie/YLAT for the purpose of allowing Muskie staff to contact me about helpful educational, employment, and community resources or opportunities. Youths Signature _______________________________ Date _________ Consent to Allow the Use of Administrative Data for Tracking and Location for NYTD Survey I, _____________________ [print name], authorize fb88 DHHS or Contracted NYTD Provider to review various kinds of administrative records (e.g., department of motor vehicle records, public assistance records, educational records, child welfare records, unemployment insurance wage records, credit bureau records, vital statistics records, and criminal justice records) to locate and contact me for follow-up NYTD surveys when I am 19 and 21 years old. 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PL^P`LhH.5?bR ,#YFWn6Dt!50Q0-T00-                           Azg                  n,C'<~3vM{UTN`@@UnknownG.[x Times New Roman5Symbol3. .[x ArialC.,.{$ Calibri Light7..{$ Calibri?= .Cx Courier New;WingdingsA$BCambria Math"1hAgAg 0 0!203q@P ?n!xxFo, %DEPARTMENT OF HEALTH & HUMAN SERVICESState of Maine Dorso, Lynn      Oh+'0 ,8 X d p|(DEPARTMENT OF HEALTH & HUMAN SERVICESState of fb88 Normal.dotm Dorso, Lynn2Microsoft Office Word@F#@j;@j; ՜.+,0  hp  State of fb88, DAFS0  &DEPARTMENT OF HEALTH & HUMAN SERVICES Title  "#$%&'()*+,-./012345679:;<=>?ABCDEFGJRoot Entry F;L1Table!-WordDocument.@SummaryInformation(8DocumentSummaryInformation8@CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q