Referring Agency Acknowledgement of Policy

Dear Referring Agency:

It is required that the Bay County Juvenile Home provide each referring agency with a copy of specific policies listed below. It is requested that you initial and sign below indicating that you have received each policy. All policies are available on the Juvenile Home website under “Parent Packet”

I have reviewed the following policies on the Bay County Juvenile Home

Please initial each:
Program Statement
Grievance Policy
Religion Policy
Intervention Standards
Seclusion Policy
Mechanical Restraint Policy
Emergency Restraint Policy
Health Status Assessment
Your signature verifies that you were able to access the polices online or received them via email. You understand that if you have questions or concerns you may speak with a Supervisor or the Director. For referring agencies this acknowledgment will last for 6 months for all youth that are lodged from your jurisdiction. A similar packet and form will be sent to the parent/guardian of the youth you place here. Please encourage parent/guardian to do the same.

For further questions or concerns I may contact:
Supervisor Joe Beauchamp or Director Juli Reynolds
Signature:*

Clear
Date:*

MonthDayYear
Date
Print name:*
Youth's Name:
Relationship to youth:
Email address to receive copy of this form*
example@example.com
Representing Court/Agency:
Attach this form into the Youth’s file
Should be Empty: