APPLICATION FOR CHILD-PLACING AGENCY LICENSE

The Commissioner of DHHS shall approve the child-placing agency license when: (1) the applicant has complied with He-C 6448.04 -.07; (2) all employees have completed the applicable central registry and criminal record checks; (3) the applicant has demonstrated that a present need for the service exists; and (4) the applicant has demonstrated the ability to accommodate the present need for services.

initial application	renewal application

APPLICANT AGENCY INFORMATION
Name of Agency:
Location Address:	NH
Street	City	State	Zip Code
Mailing Address:
Administrator:	Telephone:	Fax:
Email Address:	Website:
The agency is incorporated in New Hampshire or incorporated in another state, registered with the Secretary of State in New Hampshire, and legally authorized to do business in New Hampshire.
Profit	or	Non-Profit	Federal EIN:

SERVICE TYPE (check all applicable)
International Adoptions	Foster Care Family Assessments
Domestic Adoptions	Foster Care
Adoption Family Assessments

GEOGRAPHICAL LOCATIONS SERVED
District Office Served (check all that apply):
Berlin	Conway	Littleton	Seacoast
Claremont	Keene	Manchester	Southern
Concord	Laconia	Rochester	Statewide

CRIMINAL BACKGROUND AND STATE CENTRAL REGISTRY DISCLOSURE
All agency personnel, including volunteers and any member of the governing board that has regular contact with children shall have a criminal records background check and a state central registry check from all states in which they have resided during the past 5 years. These checks will need to be up-dated prior to renewal of the child-placing agency license, not to exceed 4 years.
The NH Criminal History Record Information Release Authorization Form (DSSP256) from the NH State Police. https://www.nh.gov/safety/divisions/nhsp/ssb/crimrecords/documents/dssp256.pdf	The NH Central Registry Name Search Authorization – 3rd Party (Form 2501) from the Division for Children, Youth and Families.

PROGRAM NARRATIVE
Use the space below to explain the required information. If more space is needed, additional sheets may be attached. Please type or print.
1.	Describe the child-placing agency’s purpose:
2.	Describe the child-placing agency’s primary sources of income:
3.	Identify and describe the population to be served:
4.	Explain the need for this service in the geographical area you wish to serve:
5.	Has your agency received a request for delivery of service from DCYF or other child-placing
agency?	yes	no	Explain:
6.	Has your agency contacted DCYF to see if there is a need for this service: Who, When and the Outcome:

FOR QUALITY ASSURANCE PURPOSES, PLEASE PROVIDE THE FOLLOWING
7.	Written description of intake procedures:
8.	Written description of criteria for entry or acceptance of clients into the child-placing agency’s program:
9.	Written description of types of therapies and interventions provided to the child to be adopted, to the foster child, to foster parents, and to the birth and adoptive parents:
10.	Written description of program monitoring procedures:
11.	Written description of foster or adoptive home licensing and approval procedures:
12.	Written description of foster or adoptive home revocation procedures:
13.	Written description of foster or adoptive home appeal procedures:
14.	Written description of staff training and development:

GOVERNING BODY MEMBERSHIP
If more space is needed, additional sheets may be attached. Please type or print.
NAME	ADDRESS	DATE APPOINTED
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ATTACHMENTS TO APPLICATION
The below required attachments MUST be sent with the application in order for the application to be processed.
Attach written statements of philosophy and policy for agency operation that addresses: Sexual harassment; Drug free workplace; Anti-discrimination; Reporting of child abuse and neglect in accordance with RSA 169-C; Discipline of children in care; Confidentiality of files and records; Minimum educational or experiential requirements for staff; Limits on the number of cases per caseworker; Documentation that criminal record and central registry checks have been obtained on every staff member; Methodology for assessment and evaluation of programs; and A contingency plan which describes how the assets and records for the agency will be transferred, processed or otherwise disseminated in the event that the agency permanently closes for business.
The child-placing agency applicant shall attach the written personnel standards that include: Titles for each position defining the salary scale, duties, and lines of authority; Job descriptions and qualifications of the administrator and casework supervisor which shall meet or exceed the requirements set forth in He-C 6448.05 (c) and (f); A description of employee benefits; Opportunities for growth through supervision, orientation, in-service training, and staff development including competency-based courses pursuant to He-C 6448.13; Annual evaluations of the work and performance of each staff member that includes provision for employee participation in the evaluation process; A description of the termination procedures established for resignation, retirement, or discharge; and A grievance procedure for employees.

ATTACHMENTS CONTINUED
Attach a copy of the child-placing agency applicant’s charter, articles of incorporation, by-laws or other policy documents demonstrating the legal authority for operating in NH;
A copy of the most recent needs assessment conducted pursuant to He-C 6448.08(a)(15);
Copy of a Certificate of Good Standing from the New Hampshire Secretary of State;
Fee schedules for adoption services provided by the child-placing agency;
For child-placing agencies in operation for at least three years, attach a copy of the most recent audited financial statements and budgets for the last three years;
For child-placing agencies in operation for less than three years, attach documentation of funding source, budget, staffing, fee schedules and contingency funds that demonstrates the agency has the fiscal capacity to operate for at least six months;
A copy of the agency specific handbook for foster and adoptive parent applicants that describe the requirements, policies, procedures, and forms; and
A copy of the current listing of personnel, including volunteers, and an organizational structural chart noting supervisory relationships and the reporting hierarchy of the child-placing agency.

CERTIFICATION
As a representative of the governing body, I certify that:
The governing body has authority over and responsibility for the operation and policy of the applicant agency;
The governing body is comprised of no less than seven persons who have knowledge of the services provided; and
The governing body does not include staff members of the applicant agency, nor have any proprietary relationship with liquid or fixed assets of any applicant agency.
Governing Body Representative (or designee) Signature	Date

AUTHORIZATION / STATEMENT OF UNDERSTANDING
I have reviewed Administrative Rule He-C 6448 and shall adhere to the rule as a licensed child-placing agency. I hereby acknowledge that DCYF personnel will be provided with access to the child-placing agency’s case records, personnel files, and other agency records in accordance with He-C 6448.07(a). I authorize the NH Division for Children, Youth and Families (DCYF) to conduct reviews to determine the agency’s compliance with Administrative Rule He-C 6448. I further understand that DCYF has the right to verify information contained in this application. The information contained in this application is correct to the best of my knowledge.
Signature of Administrator (or designee)	Date