Client Services

Education and Training Voucher (ETV) Program

Title IV-E University-Training Services

Client Services

General Documents

Form Number Form Name Form Purpose
2030 Budget for Purchase of Service ContractsExcel Spreadsheet Budget pages for cost reimbursement contracts.
2030ins (Instructions) Budget for Purchase of Service ContractsWord Document Instructions for the "Budget pages for cost reimbursement contracts" form
2031 Signature Authority DesignationWord Document 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 FormWord Document 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-908-2128Word Document Identity the 24 hour awake caregiver supervisor plan in a foster group home.
5500GEN General Invoicing ProceduresPDF Document 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 NoteWord Document Contractors must print this out and take to DFPS Diagnostic Consultation requests for signature and payment.
5645V Vendor Uniform Terms and ConditionsPDF Document DFPS Uniform Terms and Conditions for Vendors. Required for each contract.
5622VRG Regional Contracts Supplemental and Special ConditionsWord Document 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 Excel Spreadsheet 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 & AcceptanceWord Document - 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 SubcontractorsPDF Document Release of information regarding criminal history or DFPS abuse and neglect history.
2971c Request for Background Check for Purchased Client Services ContractorsPDF Document 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 SurveyExternal Link. 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 ResourcesWord Document include website links so that you may become informed on the use of these practices. [downloadWord Document]

Form Number Form Name Form Purpose
K-903-2036 Evaluation & Treatment and BIPP ReferralWord Document 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 QuestionnaireWord Document - 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 CertificationWord Document Contractor completes and submits a copy with billing and files a copy in the client record.
4502 / 4502s Evaluation and Treatment Client Satisfaction Survey QuestionnaireWord Document / SpanishWord Document 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 ServicesWord Document Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5624 / 5624s Client Orientation AcknowledgmentWord Document / SpanishWord Document 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 LogWord Document 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 VolunteersExcel Spreadsheet - 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 ReportWord Document 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 InformationWord Document 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 Word Document / SpanishWord Document 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 SurveyWord Document / SpanishWord Document 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 ServicesPDF Document Use this form to provide information about the client's contact with the substance use services screener or provider.
2063/2063s Release of Confidential InformationPDF Document / SpanishWord Document 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 ServicesPDF Document 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 Word Document 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 QuestionnaireWord Document * 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 DependencyWord Document 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 ServicesExcel Spreadsheet - 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 QuestionnaireWord Document - 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 QuestionnaireWord Document - 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 InformationWord Document Contractor ensures this document is completed and signed by client and returns form to caseworker with completed assessment.
3101 Referral for Supervised Visit ServicesWord Document Referral Form provided to Contractor by CPS Program.
3102A Parent Caretaker Observation Form / ChecklistPDF Document Visitation worker (Observer) completes this form during the supervised visit.
3103A / 3103As Supervised Visitation Expectations for Caregivers and Adult Participant(s)Word Document / SpanishWord Document 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 LogWord Document Visitation worker (Observer) ensures all who are present sign this log.
3113 Sibling Relationship ChecklistWord Document Visitation worker (Observer) completes this form during the supervised visit.
3114 Supervised Visitation Satisfaction Survey QuestionnaireWord Document 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)PDF Document Caseworker provides contact information for referral to Contractor who will provide DFPS supervision services until a placement is secured.
4505sam Supervised Visitation Caseworker Satisfaction SurveyWord Document - 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 ServicesWord Document Referral Form provided to Contractor by CPS Program.
5613 Sign-In Log for Hospital Sitting ServicesWord Document 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 AgreementWord Document / SpanishWord Document 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 ParticipateWord Document / SpanishWord Document Contractor ensures parents read and sign this form prior to conference.
0625 Family Group Decision-Making Satisfaction Survey QuestionnaireWord Document Contractor provides form to participants to complete upon conclusion of the planning conference.
0629 FGDM Conference AgendaWord Document 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 PlanWord Document 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 ConferenceWord Document 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 QuestionnaireWord Document Contractor provides form to participants to complete upon conclusion of the planning conference (PC).
0628 Permanency Conference Plan Word Document 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 ChildWord Document This form is used by conference staff during a Permanency Conference with families that have multiple children.
0628ins Permanency Conference InstructionsWord Document This form provides guidance to staff responsible for completing Form 0628, Permanency Conference Plan (PC Plan).
0628s Plan de Conferencia de PermanenciaWord Document 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 PlanWord Document 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 QuestionnaireWord Document / SpanishWord Document Contractor provides form to applicants to complete upon conclusion of the assessment.
5500 Invoicing Procedures for Assessment ServicesWord Document Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5519 Summary of QualificationsWord Document 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 ReportWord Document 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 QuestionnaireWord Document / SpanishWord Document 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 AcknowledgementWord Document 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 ParentescoWord Document Contractor ensures this document is completed and signed by client and returns form to caseworker with completed assessment.
2049 Risk Assessment FormWord Document Contractor completes this form and uses it to complete the Safety section of the Kinship Caregiver Home Assessment Template.
2700KIN Routing and Approval FormWord Document (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 ServicesWord Document Referral Form provided to Contractor by CPS Program.
6588 Kinship Caregiver Home Assessment TemplateWord Document Contractor uses template to complete the assessment (includes Intestate Compact on the Placement of Children - ICPC).
ICPC Regulation Number 2 ICPC Regulation Number 2Word Document Case manager statement provided to Contractor by CPS Program
Kinship Manual Kinship ManualPDF Document / SpanishPDF Document 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) FormWord Document Contractor uses guide to complete the HSEGH Report.
2649i HSEGH Report Instructions for ContractorWord Document Contractor uses instructions to complete the HSEGH Report.
2659 Health, Social, Education, and Genetic History (HSEGH) Additional PageWord Document Contractor uses this form when there is not enough space in Form 2649.
2700HSEGH Routing and Approval FormWord Document - 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
2191 Foster/Adoptive Home ScreeningWord Document Contractor uses template to complete the Foster/Adoptive Home Screening.
2191ins Instructions for Foster/Adoptive Home ScreeningPDF Document Contractor uses instructions to complete the Foster/Adoptive Home Screening.
2193 Foster/Adoptive Home Screening with Kinship GuideWord Document 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 ApprovalWord Document - 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 ReportPDF Document 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 AssessmentWord Document In-State Contractor completes upon request by DFPS, when one has not been provided.
5650 Contractor Visitation LogWord Document 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)

Announcement: Letter regarding Texas Adoption Resource Exchange (TARE) website updates from Audrey Deckinga, Assistant Commissioner.PDF Document

Form Number Form Name Form Purpose
2085-B Designation of Medical Consenter for Non DFPS EmployeeWord Document Contractor must use this form for the adoptive child in order to identify medical consenter and back up medical consenter.
2226 Adoptive Placement  AgreementWord Document Contractor uses this form at the placement of the child(ren) in the prospective adoptive home.
2238 Non-DFPS Adoptive Home RegistrationWord Document 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 ServicesWord Document Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
Adoption Plan Adoption PlanWord Document Contractor must complete for each child.
Checklist for Adoption Checklist for Adoption Services PaymentWord Document Contractor uses when submitting information to receive payment for services rendered.
Checklist for Post-Placement Checklist for Post-Placement Adoption Services PaymentWord Document Contractor uses when submitting information to receive payment for services rendered.
Special Needs Adoption Training Special Needs Adoption Training Curricula Resources for ContractorsWord Document 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 AuthorizationWord Document Contractor completes this form to identify appropriate services to be provided to post adoption children and families.
5500PA Post Adoption Invoicing ProceduresWord Document 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 ReportExcel Spreadsheet Contractor completes this form monthly and submits it with billing invoice.
5600  Post Adoption Service PlanWord Document Contractors complete this Service Plan to assess the adopted child and adoptive family needs and determine appropriate services.
5602 / 5602S Post Adoption Services QuestionnaireWord Document / SpanishWord Document 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 AdoptionExcel Spreadsheet 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 SummaryExcel Spreadsheet 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 AuthorizationWord Document Referral Form provided to Contractor by CPS Program.
5500PP Post Permanency Invoicing ProceduresWord Document Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5517PP Purchased Client Services Monthly Expenditures Report Excel Spreadsheet Contractor completes this form monthly and submits it with billing invoice.
5550 Post-Permanency Services Questionnaire EnglishPDF Document | SpanishWord Document Contractor provides this questionnaire to all families who received Post-Permanency services within the current contract year
5600 Post Permanency Service PlanWord Document 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 Excel Spreadsheet 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 SummaryExcel Spreadsheet 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 OrderPDF Document  

Regional Child Welfare Board/Councils (CWBC)

Form Number Form Name Form Purpose
5603 Business PlanWord Document 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/MinutesWord Document 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 ReportWord Document 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/MinutesWord Document 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 ReportWord Document 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 FormWord Document Submit with billing for reimbursement of child care during meetings.
5608 Performance Measure Data ReportWord Document 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 TrainingPDF Document 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 ServicesPDF Document Contractor uses as reference to ensure correct billing and invoicing procedures are followed and submitted to DFPS.
5501 PAL Referral FormPDF Document DFPS PAL staff provides form to Contractor for each youth.
5502 Individual Monthly Progress ReportPDF Document Contractor submits this form monthly except in September and March, when this form is required weekly.
5503 Independent Study Guide Caregiver ReportPDF Document Contractor obtains this form signed and completed from Youth.
5504 Knowledge AssessmentPDF Document Contractor administers this form one (1) time at completion of all 6 core elements of Life Skills Training.
5506 Knowledge Assessment Feedback to YouthPDF Document 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 RequirementsPDF Document Contractor submits form to DFPS CPS Contract Manager for review of staff and volunteers.
5508 Training Class SchedulePDF Document Contractor must submit a proposed schedule for each series of training sessions for DFPS PAL staff review and approval.
5509 Contractor Monthly ReportPDF Document Contractor submits this form to DFPS PAL staff on a monthly basis.
5510 Participant EvaluationPDF Document Contractor conducts an evaluation and Youth completes this form at conclusion of training series.
5510sam Participant Evaluation SampleWord Document 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 Excel Spreadsheet Contractor completes this form monthly and submits it to the contract manager with billing. This form includes the new service code 18L.

Transition and Financial Support Services

Form Number Form Name Form Purpose
5511 Contractor Monthly ReportPDF Document 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 InformationWord Document Contractor obtains this form signed and completed from Youth (includes English and Spanish).
5513 PAL Transition ReportPDF Document Contractor must complete this report during delivery of the Transitional Living Allowance.
5514 Individual Monthly Progress ReportWord Document Contractor submits this form monthly except in September and March, when this form is required weekly.
5514a Supplement to the Individual Monthly Progress ReportPDF Document 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 DescriptionsWord Document Contractor refers to these descriptions when filling out the Individual Monthly Progress Report.
5516 Initial or Review Child’s Plan of Service Signature SheetPDF Document Contractor must complete with Youth at each face to face meeting.
5518CM PAL Monthly Expenditure Report - Case ManagementExcel Spreadsheet Contractor completes this form monthly and submits it to contract manager with billing.
5518CM
(HR133)		 PAL Monthly Expenditure Report - Case Management (HR133)Excel Spreadsheet Contractor completes this form monthly to identify the expenses related to HR133.

5518PAL TFS

10/22

 PAL Transition and Financial Support Services – Contractor Billing Report Excel Spreadsheet

Contractor completes this form monthly and submits it to contract manager with billing. This form includes service codes 20B and 20C.

5518PAL TFS (HR133)

9/21

 PAL Transition and Financial Support Services – Contractor Billing Report Excel Spreadsheet Contractor completes this form monthly and submits it to contract manager with billing. This form includes service codes 20B and 20C.
5525 Pre-Transitional Monthly Progress ReportPDF Document Contractor documents contacts and services with individual youth or young adults in the pre-transition stage.
5526 Post-Transitional Monthly Progress ReportPDF Document Contractor documents contacts and services with individual clients in the post-transition stage.
5617 / 5617s PAL Transition Support Services Participant EvaluationPDF Document / SpanishWord Document 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 PDF Document 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 PlanWord Document Contractor must refer to this form to assist Youth identify action items during each core element of the training.
5006i PAL Contractor GuideWord Document Contractor uses guide to follow the Budget Summary provided monthly by contract staff.
5618 Contract Performance Measures Data Reporting FormWord Document 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 EvaluationWord Document 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 EvaluationWord Document 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) ProgramWord Document 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 flyerPDF Document.

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 ContractsExcel Spreadsheet 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 DocumentationWord Document Contractors complete to document training.
Attachment B Plan of OperationWord Document 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)Word Document Agreement for BSW/MSW students (part-time or full-time), beginning the Stipend Program in Fall 2013 and thereafter.
2282STUDNTMSW Employee Agreement (MSW)Word Document Agreement for MSW students (part-time or full-time), beginning the Stipend Program in Fall 2013 and thereafter.
2282STUDNTBSW1 Employee Agreement (BSW1)Word Document Agreement for BSW students beginning the Stipend Program in Fall 2013 and thereafter.
7039 Stipend Student Information Excel SpreadsheetExcel Spreadsheet Contractors use this form to provide student information that is transferred into the Stipend Agreements.