home page collage of pictures

INQUIRY TO OPERATE A CHILD PLACING AGENCY

The inquiry form has been made available via the internet. The form can be downloaded in either microsoft word or as a pdf document. The microsoft word document is interactive. Answer the questions in the computer, print the form, sign the form and mail it to the address indicated.

Child Placing Agency Inquiry Form

Word Version

PDF Version

Once the form is completed please print the form and attach the following:

Attach the Following:

A Needs Assessment for the county/counties you plan to serve [At a minimum describe the clients you plan to serve (if applicable, include the levels of children you plan to serve), the number of clients you anticipate needing your service, funding sources, referral sources (list agencies that will refer clients to you), any other documentation that describes the need for your service(s)].
A proposed line-item budget detailing expenses and revenues. Include your fee schedule. Include specific sources of revenues. If you provide family foster care services you will not be eligible to participate in the rate setting process until you have been licensed, in business for a year, meet the requirements of the DHHS Controller’s Office and complete the necessary contracting package. You will be eligible to receive the North Carolina Standard Board Rate for children eligible for these funds during this first year of operation. Describe your plan for meeting your budgetary needs during the first year of operation.
The names of three references with addresses and phone numbers [two of the references must be from current or former employers]. If you operated a child-placing agency, maternity home or residential child care facility (group home) in another state provide the name, address and phone number of a contact person with the licensing authority in that state.
A list of all the owners (co-owners, partners, shareholders, principals, affiliates) of the agency with their full legal names, addresses, phone numbers and social security numbers. Indicate percentage of ownership for each owner.
A list of the Board of Directors with addresses, classifications and terms of service.
A certified copy of your college transcripts. [Please note that Licensing Regulations require that Agency Administrators have at a minimum a bachelor's degree from a school accredited by the Association of Colleges and Schools and at least four years experience in a human services program of which a minimum of two years has been in administration. Social Workers must have either a master's degree in social work or related field of study from a school accredited by the Association of Colleges and Schools or a bachelor's degree in social work or a related field and two years experience working directly with children. Social Work Supervisors must have at a minimum a master's degree in social work or related area of study from a school accredited by the Association of Colleges and Schools or a bachelor's degree in social work or a related field and two years experience working directly with children.].
Documentation that you have at least four years experience in a human services program of which a minimum of two years has been in administration.

Submit this Inquiry Form to:
North Carolina Division of Social Services
Regulatory and Licensing Services
952 Old US Highway 70
Black Mountain, North Carolina 28711

Administrative Rules for Child Placing Agencies, Family Foster Homes, Therapeutic Foster Homes and Adoptions are found in North Carolina Administrative Code Chapter 10A, Subchapters 70F, 70G, 70H and 70E.