Effective Date: 




Updated: 4/2017



Form 4201 is used to:

  • identify and document the reason a surrogate parent is needed, and
  • assign a surrogate parent.

Detailed Instructions

File the original form in the child’s record. If a surrogate parent is assigned, provide a copy to the surrogate parent.


Note about Retention

Unless a longer period is required by state or federal law, the contractor must retain records for five years after the child has been dismissed from services.

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