Genesis Youth Crisis Center, Inc.
P.O. Box 546 ~ 192 Safe Haven Drive ~ Clarksburg, WV 26302
Phone (304) 622-1907 ~ Fax (304) 623-9346
PLACEMENT AGREEMENT
Resident Name _______________________________ Admission Date_____/______ /_____
Genesis Youth Crisis Center, lnc. (GYCC) is a private, non-profit organization, and is licensed by the WV Department of Health
and Human Resources and the WV Office of Behavioral Health Services to provide Residential Crisis Support/Emergency
Shelter Services. GYCC agrees to provide services in accordance with standards established by the Office of Social Services,
Bureau of Medical Services, and all applicable regulatory agencies.
As a resident of this facility, he/she may participate in all planned educational, therapeutic, and recreational activities and field
trips outlines in the program. This includes activities, which involve other GYCC facilities. Permission from the social
worker/legal guardian will be obtained for any off campus activities in which GYCC staff will not be supervising the resident.
Any stipulation or request, which may limit his/her ability to participate in the program, should be discussed at admission if
possible. GYCC will make reasonable accommodations to comply with such requests, however reserves the right to deny such
requests if the stipulation will cause disruption to the daily operations of the facility.
The resident will be assigned a case manager, and the treatment team will coordinate necessary services and develop a treatment
plan to identify specific treatment goals for the resident. The social worker/legal guardian is expected to provide necessary
information regarding the resident's case to the shelter and participate in the treatment planning process which entails weekly
treatment meetings up until their 30th day in care. The social worker/legal guardian shall also communicate with the resident and
agency in accordance with DHHR Foster Care Policy. The case manager will provide a progress report every 30 days and assist,
when appropriate, in making recommendations, submitting court reports, making referrals and arranging pre-placement
interviews.
GYCC agrees to provide a safe, non-restrictive and supportive setting. Shelter staffs are responsible for knowing the
whereabouts of residents at all times. GYCC shelters are staff secure, which means staffs have the ability to restrict or limit
activities, but there are no construction fixtures designed to restrict or limit residential activities. The resident is considered to be
"Away from Supervision" if he/she is absent from the supervision of staff without consent for more than 15 minutes. If the
resident leaves the facility, staff will make a reasonable attempt to follow the resident, according to the AFS Training curriculum.
If the resident runs away, shelter staff will immediately contact: local law enforcement, DHHR (hotline after hours), GYCC on
call worker, the resident's family if appropriate, and the office of the circuit court judge involved in his/her placement. Shelter
staff will make the same notifications when the resident is located or returned to the facility. GYCC will discharge the resident if
not located or returned within 24 hours of the time of elopement.
Placement in emergency shelters is limited to 30 days. If the resident's stay is going to exceed this time limit, the social
worker/legal guardian may request an extension from this facility for up to an additional 60 days if deemed necessary by the
MDT and the appropriate re-authorization request has been approved by the Administrative Services Organization.
Should the resident display symptoms or functional impairment, which cannot be treated safely and effectively in this
facility, GYCC will request the resident be discharged. Shelter staff will assist in making referrals and transporting the resident to
an alternative placement as recommended and agreed upon by the MDT (if possible) or the social worker/legal guardian. One-onone supervision may be provided in emergency situations for a period not "to exceed 24 hours.
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Resident Signature
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Date
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Legal Guardian Signature
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Date
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GYCC Staff Signature
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Date