Children in Group / Case Information Form

Group
number / 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