CLIENT INFORMATION CHECKLIST
CHILD'S D.O.B:
CHILD'S AGE:
MOTHER'S NAME:
FATHER'S NAME:
SIBLINGS' NAMES:
SIBLINGS' D.O.B.:
6. IMPORTANT DATES:
DATE CHILD REMOVED FROM HOME:
DATE DEPENDENCY PETITION FILED:
DATE MOTHER SERVED:
DATE FATHER SERVED:
DATE OF TEMPORARY CUSTODY HEARING:
-OUTCOME OF TEMPORARY CUSTODY HEARING:
DATE OF INITIAL HEARING/SETTLEMENT CONFERENCE:
-SETTLEMENT REACHED:
DATE CHILD ADJUDICATED DEPENDENT AS TO MOTHER:
DATE CHILD ADJUDICATED DEPENDENT AS TO FATHER:
CHILD'S ADDRESS:
CHILD'S TELEPHONE NO.:
SECOND PLACEMENT DATE:
CHILD'S ADDRESS:
CHILD'S TELEPHONE NO.:
THIRD PLACEMENT DATE:
CHILD'S ADDRESS:
CHILD'S TELEPHONE NO.:
FOURTH PLACEMENT DATE:
CHILD'S ADDRESS:
CHILD'S TELEPHONE NO.:
FOSTER MOM'S NAME:
FOSTER MOM'S WORK NUMBER:
FOSTER DAD'S NAME:
FOSTER DAD'S WORK NUMBER:
GRADE:
SCHOOL NAME:
SCHOOL ADDRESS:
SCHOOL TELEPHONE NO.:
TEACHER'S NAME:
SPECIAL ED. TEACHER'S NAME:
SCHOOL COUNSELOR:
TUTOR:
DATE ASSIGNED TO CASE:
CPS INTAKE WORKER'S ADDRESS:
CPS INTAKE WORKER'S TELEPHONE NO.:
CPS ONGOING WORKER'S NAME:
DATE ASSIGNED TO CASE:
CPS ONGOING WORKER'S ADDRESS:
CPS ONGOING WORKER'S TELEPHONE NO.:
DDD CASE WORKER'S NAME:
DATE ASSIGNED TO CASE:
DDD CASE WORKER'S ADDRESS:
DDD CASE WORKER'S TELEPHONE NO.:
CASA'S NAME:
DATE APPOINTED TO CASE:
CASA'S TELEPHONE NO.:
VISIT SUPERVISOR'S NAME:
DATE ASSIGNED TO CASE:
VISIT SUPERVISOR'S ADDRESS:
TELEPHONE NO.:
DATES SUPERVISED VISITS BEGAN:
-DATES YOU HAVE SUPERVISED VISITS:
-PLACE OF VISITS:
-FREQUENCY OF VISITS:
-DURATION OF VISITS:
CHILD'S THERAPIST'S NAME:
THERAPIST'S ADDRESS:
THERAPIST'S TELEPHONE NO.:
DATE ASSIGNED TO CASE:
NAME OF CHILD'S PSYCHIATRIST:
ADDRESS OF PSYCHIATRIST:
TELEPHONE NO. OF PSYCHIATRIST:
NAME OF MENTAL HEALTH WORKER:
DIAGNOSIS:
MEDICATIONS & DOSAGES:
DATES OF MENTAL HEALTH HOSPITALIZATIONS:
CHILD'S DOCTOR'S NAME:
TYPE OF DOCTOR:
ADDRESS OF DOCTOR:
TELEPHONE NO. OF DOCTOR:
DIAGNOSIS:
TREATMENT:
MEDICATIONS & DOSAGES:
DATES OF HOSPITALIZATIONS & /OR SURGERIES:
PHYSICAL THERAPIST'S NAME:
PHYSICAL THERAPIST'S ADDRESS:
PHYSICAL THERAPIST'S TELEPHONE NO.:
DATE ASSIGNED TO CASE:
OCCUPATIONAL THERAPIST'S NAME:
OCCUPATIONAL THERAPIST'S ADDRESS:
OCCUPATIONAL THERAPIST'S TELEPHONE NO.:
DATE ASSIGNED TO CASE:
SPEECH THERAPIST'S NAME:
SPEECH THERAPIST'S ADDRESS:
SPEECH THERAPIST'S TELEPHONE NO.:
DATE ASSIGNED TO CASE:
ADDRESS OF PARENT AIDE:
TELEPHONE NO. OF PARENT AIDE:
DATE ASSIGNED:
MOTHER'S THERAPIST'S NAME:
MOTHER'S THERAPIST'S ADDRESS:
MOTHER'S THERAPIST'S TELEPHONE NO.:
-SESSIONS BEGAN:
-FREQUENCY OF SCHEDULED SESSIONS:
-FREQUENCY OF SESSIONS ATTENDED BY MOM:
-MOTHER'S TREATMENT GOALS:
FATHER'S THERAPIST'S NAME:
FATHER'S THERAPIST'S ADDRESS:
FATHER'S THERAPIST'S TELEPHONE NO.:
-DATE SESSIONS BEGAN:
-FREQUENCY OF SCHEDULED SESSIONS:
-FREQUENCY OF SESSIONS ATTENDED BY DAD:
-FATHER'S TREATMENT GOALS:
FAMILY THERAPIST'S NAME:
FAMILY THERAPIST'S ADDRESS:
FAMILY THERAPIST'S TELEPHONE NO.:
-DATE SESSIONS BEGAN:
-FREQUENCY OF SCHEDULED SESSIONS:
-FREQUENCY OF SESSIONS ATTENDED BY MOM:
-FREQUENCY OF SESSIONS ATTENDED BY DAD:
-FREQUENCY OF SESSIONS ATTENDED BY CHILD:
-FAMILY'S TREATMENT GOALS:
MOTHER'S SUBSTANCE ABUSE THERAPIST'S NAME:
MOTHER'S SUBSTANCE ABUSE THERAPIST'S ADDRESS:
MOTHER'S SUBSTANCE ABUSE THERAPIST'S TELEPHONE NO.:
-DATE SESSIONS BEGAN:
-FREQUENCY OF SCHEDULED SESSIONS:
-FREQUENCY OF SESSIONS ATTENDED BY MOM:
-MOTHER'S TREATMENT GOALS:
FATHER'S SUBSTANCE ABUSE THERAPIST'S NAME:
FATHER'S SUBSTANCE ABUSE THERAPIST'S ADDRESS:
FATHER'S SUBSTANCE ABUSE THERAPIST'S TELEPHONE NO.:
-DATE SESSIONS BEGAN:
-FREQUENCY OF SCHEDULED SESSIONS:
-FREQUENCY OF SESSIONS ATTENDED BY DAD:
DATE COURT ORDERED UA'S FOR MOTHER:
FREQUENCY OF DROPS ORDERED:
ARE DROPS TO BE RANDOM:
ARE DROPS TO BE SUPERVISED:
HAS COURT ADVISED MOTHER THAT A MISSED CALL IS A POSITIVE:
-IF SO, DATE ORDERED:
HAS COURT ADVISED MOTHER THAT A MISSED DROP IS A POSITIVE:
-IF SO, DATE ORDERED:
NAME OF MOM'S PSYCHIATRIST:
ADDRESS OF PSYCHIATRIST:
TELEPHONE NO. OF PSYCHIATRIST:
NAME OF MENTAL HEALTH WORKER:
ADDRESS OF MENTAL HEALTH WORKER:
MENTAL HEALTH WORKER'S NO.:
DIAGNOSIS:
MEDICATIONS & DOSAGES:
MOM'S TREATMENT GOALS:
DATES OF MENTAL HEALTH HOSPITALIZATIONS:
NAME OF DAD'S PSYCHIATRIST:
ADDRESS OF PSYCHIATRIST:
TELEPHONE NO. OF PSYCHIATRIST:
NAME OF MENTAL HEALTH WORKER:
MENTAL HEALTH WORKER'S NO.:
MENTAL HEALTH WORKER'S ADDRESS:
DIAGNOSIS:
MEDICATIONS & DOSAGES:
DAD'S TREATMENT GOALS:
DATES OF MENTAL HEALTH HOSPITALIZATIONS:
MOM'S PROBATION OFFICER'S NAME:
PROBATION OFFICER'S ADDRESS:
PROBATION OFFICER'S TELEPHONE NO.:
DATE ASSIGNED TO CASE:
PROBATION CONDITIONS:
MOM'S DEFENSE ATTORNEY'S NAME:
DEFENSE ATTORNEY'S ADDRESS:
DEFENSE ATTORNEYS' TELEPHONE NO.:
DATE ASSIGNED TO CASE:
MOM CONVICTED OF:
DATE OF CONVICTION:
SENTENCE:
DAD'S PROBATION OFFICER'S NAME:
PROBATION OFFICER'S ADDRESS:
PROBATION OFFICER'S TELEPHONE NO.:
DATE ASSIGNED TO CASE:
PROBATION CONDITIONS:
DAD'S DEFENSE ATTORNEY'S NAME:
DEFENSE ATTORNEY'S ADDRESS:
DEFENSE ATTORNEY'S TELEPHONE NO.:
DATE ASSIGNED TO CASE:
DAD CONVICTED OF:
DATE OF CONVICTION:
SENTENCE:
PROBATION OFFICER'S ADDRESS:
PROBATION OFFICER'S TELEPHONE NO.:
DATE ASSIGNED TO CASE:
PROBATION CONDITIONS:
CHILD'S DEFENSE ATTORNEY'S NAME:
DEFENSE ATTORNEY'S ADDRESS:
DEFENSE ATTORNEY'S TELEPHONE NO.:
DATE ASSIGNED TO CASE:
CHILD'S CONVICTED OF:
DATE OF CONVICTION:
SENTENCE:
REVIEW BOARD ("FCRB"):
WHAT ARE THE CONCERNS OF FCRB:
WHAT ARE THE RECOMMENDATIONS OF FCRB:
HAS CHILD SUPPORT BEEN ORDERED:
-IF SO, WHEN WAS IT ORDERED:
-IF SO, HOW MUCH WAS ORDERED:
HAS A PERMANENCY PLANNING HEARING BEEN SET:
-IF SO, WHEN:
-WHAT IS THE PERMANENT PLAN:
HAVE PARENTS SIGNED A RELEASE OF INFORMATION:
-IF SO, FOR WHOM:
HAS MOTHER HAD A PSYC. EVAL.:
-IF SO, WHEN:
-IF SO, BY WHOM:
-IF SO, DIAGNOSIS:
-IF SO, TREATMENT GOALS:
HAD FATHER HAD PSYC. EVAL:
-IF SO, WHEN:
-IF SO, BY WHOM:
-IF SO, DIAGNOSIS:
-IF SO, TREATMENT GOALS:
-ISSUES DEALT WITH AT HEARING AND THEIR PROPOSED RESOLUTION:
-ISSUES TO BE REVIEWED AT NEXT HEARING:
-JUDGE'S CONCERNS & COMMENTS:
-WERE REASONABLE EFFORTS FINDING MADE & IF NOT, WHY NOT:
DATE OF SECOND DEPENDENCY REVIEW HEARING:
-ISSUES DEALT WITH AT HEARING & THEIR PROPOSED RESOLUTION:
-ISSUES TO BE REVIEWED AT NEXT HEARING:
-JUDGE'S CONCERNS & COMMENTS:
-WERE REASONABLE EFFORTS FINDING MADE & IF NOT, WHY NOT:
DATE OF PERMANENCY PLANNING HEARING:
-CASE PLAN ADOPTED:
14. CHILD'S WISHES
PLACEMENT:
-WITH WHOM DOES CHILD WANT TO LIVE:
-DOES CHILD FEEL SAFE RETURNING HOME:
-IF SO, WHY: WHAT HAS CHANGED FOR CHILD:
-HOW IS PLACEMENT TREATING CHILD:
-HAS ANYONE HARMED THE CHILD IN THE PLACEMENT:
-IS PLACEMENT LISTENING TO CHILD'S CONCERNS:
-DOES CHILD FEEL HE/SHE IS BEING TREATED FAIRLY BY PLACEMENT:
-HOW IS CHILD BEING TREATED BY OTHER CHILDREN IN PLACEMENT:
-HOW IS CHILD FITTING IN WITH RULES OF THE PLACEMENT:
LEGAL CUSTODY:
-DOES CHILD WANT LEGAL CUSTODY RETURNED TO PARENT(S):
-IF SO, WHY: WHAT HAS CHANGED FOR CHILD:
VISITATION WITH MOTHER:
-FREQUENCY :
-DURATION:
-LOCATION:
-SUPERVISED:
-SUPERVISED BY WHOM:
-CONCERNS:
VISITATION WITH FATHER:
-FREQUENCY:
-DURATION:
-LOCATION:
-SUPERVISED:
-SUPERVISED BY WHOM:
-CONCERNS:
VISITATION WITH SIBLINGS:
-FREQUENCY:
-DURATION:
-LOCATION:
-SUPERVISED:
-SUPERVISED BY WHOM:
-CONCERNS:
SERVICES:
-INDIVIDUAL THERAPY:
-FAMILY THERAPY:
-GROUP THERAPY:
-LIKE THERAPIST:
-FREQUENCY:
-DURATION:
-CONCERNS:
-MEDICATIONS:
-TUTORING:
-EXTRACURRICULAR ACTIVITIES:
-MEDICAL TREATMENT:
SCHOOL ACADEMIC PERFORMANCE:
SCHOOL BEHAVIORAL PERFORMANCE:
15. NOTES