Children in Group / Case Information Form
Groupnumber / Group
Identifier / Date
submitted / Form # of
Priority Case?
Child Last name Child First name
Middle name Also known as
Gender m M m F Date of Birth Social Security #
Ethnicity (34) m African-American m Asian-American m Caucasian m Latino m Native American
m Other m Unknown
Primary Language (15) m English m French m Other m Signing m Spanish
Other Language (15) m English m French m Other m Signing m Spanish
Number of placements before assignment to CASA # months in prior placements
School Grade
Disabilities (6) m Cardiac m Cerebral palsy m Circulatory m Hearing
m Learning disabilities mMental retardation m Mobility m Neurological
m None m Other m Psychological m Reactive attachment m Respiratory
Referred by (3) m Attorney m Judge m Social service agency
Child removed from home? m Yes m No Date removed
Removed from (8)
m Aunt m Brother m Father m Father’s partner m Guardian
m Maternal grandfather m Maternal grandmother m Mother m Mother’s partner
m Parents m Paternal grandfather m Paternal grandmother m Sister
m Stepfather m Stepmother m Uncle m Other
Date of most recent reasonable efforts determination
Status of case at program assignment (13)
m Adjudication m Adjudication and disposition m Adoption
mDisposition/permanency planning m Foster care review m Preliminary protective
m Review—18 months m Review—12 months m Review—6 months m Review – other
m Social-service review m Termination of parental rights m Other
Date assigned to program
County of Residency (42)
Zip of Residency (41)
User Defined Eligible status category?
Initial case notes
Case Closing Information
Date Court Closed Case
Date Program Closed Case
Reason for court closure (2) m Death of child m Child turned 18/21 m Adopted
m Returned to family m Placed with legal guardian m Child ran away m Case removed from docket
m Case transferred m Family moved m Other
Placement at court closure (9) m Own home m Other m Third-party custody
m Therapeutic foster home m Residential treatment facility m Relative placement m Non-relative foster care
m Non-relative adoption m Independent living program m Hospital m Guardianship
m Group home m Emergency shelter m Detention center
Reason for program closure (2) m Death of child m Child turned 18/21 m Adopted
m Returned to family m Placed with legal guardian m Child ran away m Case removed from docket
m Case transferred m Family moved m Other
CASA Permanent placement recommendation accepted? m Yes m No
Case Worker Permanent placement recommendation different? m Yes m No
Closing Notes:
Entered into COMET by Date
2/2 Children in Group.Case Information Formrev.doc 3/14/2005