(Child in Substitute Care, DHS has Custody)
Case Name: / Case Number: /
Worker: / Date: / // /
Branch: /
Child Information
Child’s Name: / Person Letter:
Date of Birth: / Age: / Primary Language
Most Recent Removal from Home:
Mother Information:
Mother’s Name: / Date of Birth: / //
Primary Language:
Father’s Information
Father’s Name: / Date of Birth: / //
Primary Language: / Father’s Legal Status:
Legal Status:
Identified Safety Threats
Identified Safety Threats:
Safety Analysis
Safety Analysis:
Disposition
Disposition:
Indian Child Welfare Summary
Indian Child Welfare Summary:
Hearing Information
Type of Hearing:
Type of Hearing Narrative:
Legal Information
Jurisdictional Basis:
Location of Child
Type of Placement(s):
Type of Placement(s) Narrative:
Relative Search and Current Placement
Relative Search and Current Placement:
Child Safety and Well Being
Child Description, Their Needs and Well-Being:
Youth Transitional Programs and Services:
Protective Capacity
Relationship:
Protective Capacity:
Relationship:
Protective Capacity:
Reasonable/Active Efforts to Prevent Placement
Reasonable/Active Efforts to Prevent Placement:
Ongoing Safety Plan
Ongoing Safety Plan:
Visitation Plan
Visitation Plan:
Permanency Planning
Case Plan Development:
Primary Permanency Plan:
Explanation:
Conditions to Return:
Expected Outcomes:
Actions:
Concurrent Permanency Plan:
Explanation:
Progress to Date:
Primary and Concurrent Permanency Plan Parental Discussion:
Filing Decision
Filing Decision:
Substitute Caregiver Information:
Substitute Caregiver Information:
Face – to – Face Contact
Caseworker Contact with Child and Parent:
Contact Dates and Child:
Contact Dates and Mother:
Contact Dates and Father:
Contact Dates with Relative Caregiver/Foster Parent/Provider:
Collaterals, Relatives and Others:
Child and Family Information
MOTHER INFORMATION CONFIDENTIAL ADDRESS
Mother’s Name:
Whereabouts:
Bldg/Apt#: Street:
City/State/Zip Code:
Phone Number: ()
FATHER INFORMATION CONFIDENTIAL ADDRESS
Father’s Name:
Whereabouts:
Bldg/Apt#: Street:
City/State/Zip Code:
Phone Number: ()
CASA INFORMATION
CASA Name:
Bldg/Apt#: Street:
City/State/Zip Code:
Phone Number: ()
ATTORNEY INFORMATION
Attorney Name:
Representing: Select OneMotherFatherChild
Bldg/Apt#: Street:
Phone Number: ()
OTHER SIGNIFICANT PERSONS/RELATIVES
Name:
Relationship:
Bldg/Apt#: Street:
City/State/Zip Code:
Phone Number: ()
Additional Information
Signatures
Caseworker: ______Date: ______
Supervisor: ______Date: ______
Parent/Legal Guardian: ______Date: ______
Parent/Legal Guardian: ______Date: ______
Mailing Information
Copies of this form mailed by: (Signature) ______Date: ______
To:Mother:______Date: ______
Father:______Date: ______
Attorney: ______Date: ______
Legal Guardian: ______Date: ______
Policy Ref.: I-1.2 , I-B.3.1 CF 333A (3/07)
FILE: Narrative Section Page 2 of 4