Placer County Systems of Care

Presumptive Transfer Notification

This notice is pursuant to AB1299 & Welfare and Institutions Code section 14717.1 (f)

This notice is to provide notice regarding the status of responsibility of specialty mental health services for the following child/NMD:

Child's Name:

Date of Birth:

Name:

Email:

Phone #:

Name:

Email:

Phone #:

Placement Name:

Date of Placement:

Placement Email:

Placement Phone #:

Placement Address:

Select all which apply:

STRTP

THP+

Relative Placement

Resource Home, Agency

Resource Home or Agency:

PRESUMPTIVE TRANSFER WILL BE WAIVED and placing county will remain responsible for the provision of Mental Health services.

Reason for Presumptive Transfer Waiver: (check one)

It is determined the transfer would disrupt continuity of care or delay access to services provided to the minor/Non-minor dependent (NMD).

It is determined the transfer would interfere with family reunification efforts documented in the child welfare/probation case plan.

The youth/NMD’s placement in the receiving county is expected to be less than six months.

The foster child/NMD’s residence is within 30 minutes of travel to the mental health provider in the placing county.

PRESUMPTIVE TRANSFER DOES APPLY and receiving county will be responsible for authorization, provision and payment for mental health services to the county where the minor/NMD is placed.

THIS PRESUMPTIVE TRANSFER NOTIFICATION IS CONSIDERED URGENT.

Minor/NMD is CURRENTLY in services:

Yes

No

Name of Agency:

Please include copy of last MH assessment and summary of services and treatment

Name:

Email:

Phone #:

List any urgent or crisis needs:

Target mental health symptoms/Reason for referral:

Kindly attach any relevant documents to this form. Please send any additional documents, court reports, court orders, previous assessments, CFT notes, etc to the email inbox (CWSMHTransfer@placer.ca.gov) if you are unable to attach them when submitting this form.

In the event that the form contains errata, Placer County requires your email address to send this form back for review. Please enter it into the box below.

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CARE447 Presumptive Transfer Notification

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