Case Management Resources
The files listed below are available for review and download.
FORMS FOR ACCESS (Automated Community Connection to Economic Self-Sufficiency)
FORMS FOR ADOPTIONS SUBSIDY PROCESS
- Adoption Subsidy Request Checklist (doc - 34 KB) -
- Adoption Assistance Agreement (pdf - 171 KB) -
- Adoption Subsidy Disclaimer (pdf - 119 KB) - Form 5172
- Title IV-E and Medicaid Application (pdf - 337 KB) - Form 2626A
- Declaration of US Citizenship (pdf - 410 KB) - Form 2058
- MAS TANF Worksheet/Application (pdf - 190 KB) - Form 5263
- Memorandum of Agreement (pdf - 120 KB) - Form 5072
- Reasonable Efforts to Place without Subsidy (doc - 29 KB) -
- Subsidized Adoption Program Child's Summary (pdf - 363 KB) - Form 5075
- Subsidized Adoption Program Data Sheet (pdf - 376 KB) - Form 5078
- Subsidized Adoption Program Disposition Sheet (pdf - 363 KB) - Form 5077
- Tuition and Fee Waiver Form (doc - 82 KB) -
FORMS FOR CHILD CARE
FORMS FOR CLIENT TRUST FUNDS
FORMS FOR FOSTER HOME LICENSING
- List of Licensing Forms (22 - 41 KB) -
- Release of Information (doc - 36 KB) - Form A
- Abuse Registry Form and Residence List (doc - 76 KB) - Form B1
- Residence List (doc - 24 KB) - Form B2
- Affidavit of Good Moral Character and Addendum (pdf - 163 KB) - Form C
- Employment Reference (doc - 64 KB) - Form D
- Personal Reference (doc - 75 KB) - Form E
- School Reference (doc - 44 KB) - Form F
- EPSDT (doc - 26 KB) - Form G
- Confidentiality Statement (doc - 44 KB) - Form H
- Bilateral Agreement (doc - 62 KB) - Form I
- Discipline Policy and Signature Page (doc - 36 KB) - Form K
- Firearm Safety Affidavit (doc - 38 KB) - Form L
- Health Certificate (doc - 38 KB) - Form M
- Water Safety Affidavit (doc - 52 KB) - Form N
- Release of Information for Foster Parent Association (doc - 38 KB) - Form O
- Disaster Form (doc - 42 KB) - Form P
- HIPPA (pdf - 46 KB) - Form Q
- Licensing Affidavit (doc - 45 KB) - Form R
- MAPP Requirements (doc - 43 KB) - Form S
- Medications List (doc - 42 KB) - Form T
FORMS FOR RELATIVE CAREGIVER
- Checklist for customers of Relative Caregiver Program (doc - 58 KB) -
- Relative Caregiver Process Improvements (doc - 120 KB) -
FORMS FOR TANF
- Definition - Specified relatives, Ch. 65A-1.705, F.A.C. (doc - 22 KB) -
- Qualified Non-Citizen Status and Required Documentation Requirements (doc - 36 KB) -
- Request for TANF Funds (doc - 102 KB) - Form 5244
FORMS FOR TITLE IV-E AND MEDICAID ELIGIBILITY DETERMINATION
- Declaration of US Citizenship (pdf - 410 KB) - Form 2058
- Eligibility Review and Change Report (pdf - 222 KB) - Form 2694
- Medicaid Application (pdf - 295 KB) - Form 2293
HEALTHY FAMILIES
- Healthy Families Brochure (doc - 686 KB) -
- Healthy Families Referral Form (doc - 24 KB) -
- STEP Brochure (doc - 919 KB) -
- STEP Class Schedule 2007 (doc - 36 KB) -
HEARTLAND FOR CHILDREN DOCUMENTS
HELPFUL PHONE NUMBERS
MEDICAID PROVIDERS
- Hardee County Providers (pdf - 61 KB) -
- Highlands County Providers (pdf - 103 KB) -
- Polk County Providers (pdf - 242 KB) -
PRE-SERVICE TRAINING SCHEDULES
RESOURCES
- Child Protection Acronym List (doc - 70 KB) -
- Medicaid Fact Sheet (doc - 108 KB) -
- Resource Links (doc - 68 KB) -
SCHOOL RESOURCES
SUBSTANCE ABUSE AND MENTAL HEALTH RESOURCES
- Authorization for CBHA (doc - 34 KB) -
- Community Mental Health Flow Chart (xls - 74 KB) -
- Comprehensive Behavioral Health Assessment Referral (doc - 76 KB) -
- Guide to Children's Mental Health Services (doc - 170 KB) -
- MTD Staffing Flow Chart (xls - 44 KB) -
- SAMH Referral Form ( - 118 KB) -
- SIPP & STGC Flow Chart (xls - 40 KB) -
- Threshold Criteria (doc - 78 KB) -