ORIGINAL DISPOSITION REPORT TO THE COURT

Use of form: The information on this form conforms to the requirements of 48.33 and 938.33 Wis. Stats., and related statutes. It is mandatory under the terms of the State / County Contract and other provisions relating to the statewide automated child welfare information system. Personally identifiable information on this form will be used for identification purposes only.

Name - Judge / Hearing Date (mm/dd/yyyy) / eWiSACWIS Case Number
Court Number
/ County / Case Type

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Name (Last, First, MI, Suffix) / Birthdate / Age
Address (Street, City, State, Zip Code) / Telephone Number
Current Caregiver
Name - Caregiver 1 (Last, First, MI, Suffix) / Name - Caregiver 2 (Last, First, MI) / Relationship to
Address (Street, City, State, Zip Code) / Telephone Number
Mother Unknown Deceased
Name (Last, First, MI) Status: Birth Adoptive / Birthdate
Address (Street, City, State, Zip Code) / Telephone Number
Marital Status
Married Single Widowed Divorced / Name - Spouse
Father Unknown Deceased
Name (Last, First, MI, Suffix) / Birthdate
Address (Street, City, State, Zip Code) / Telephone Number
Marital Status
Married Single Widowed Divorced / Name - Spouse
Status: Adjudicated Adoptive Alleged Presumptive

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Tribal Information

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Name:
Yes No / Is the an American Indian?
If Yes, name of American Indian Tribe or Band:

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Yes No / If the above child(ren) / juvenile(s) is / are American Indian, has / have the Tribe(s) been notified of these proceedings?
Verification of American Indian status provided by:
I. / Jurisdiction
Include all 48.13 and 938.12 statutes and the proper subsection(s) that apply for each child / juvenile.
Name - Child / Juvenile / Jurisdiction
II. / Agency's Recommended Finding
Name - Child / Juvenile / Agency’s Recommended Finding
Child in Need of Protection or ServicesCHIPS / DelinquencyCHIPS / JIPSConsent DecreeCHIPS / Delinquent / JIPSDelinquentDelinquent / JIPSJuvenile in Need of Protection or Services
Child in Need of Protection or ServicesCHIPS / DelinquencyCHIPS / JIPSConsent DecreeCHIPS / Delinquent / JIPSDelinquentDelinquent / JIPSJuvenile in Need of Protection or Services
Child in Need of Protection or ServicesCHIPS / DelinquencyCHIPS / JIPSConsent DecreeCHIPS / Delinquent / JIPSDelinquentDelinquent / JIPSJuvenile in Need of Protection or Services
Child in Need of Protection or ServicesCHIPS / DelinquencyCHIPS / JIPSConsent DecreeCHIPS / Delinquent / JIPSDelinquentDelinquent / JIPSJuvenile in Need of Protection or Services
Child in Need of Protection or ServicesCHIPS / DelinquencyCHIPS / JIPSConsent DecreeCHIPS / Delinquent / JIPSDelinquentDelinquent / JIPSJuvenile in Need of Protection or Services
III. / Description of Current Situation Regarding Child / Juvenile and Family
Include names and living situation of all siblings.
IV. / Social History Narrative
Describe the history of the family, important relatives, and others as appropriate to provide sufficient knowledge for the court to make informed decisions regarding the disposition, services, and conditions. Consider information related to previous agency referrals, family court history, relevant information about the child, siblings, parents and parent figures (including strengths, needs, history of prior services, etc.), family functioning, and professional evaluations / assessments.
V. / Placement History
Include name of placement and dates, beginning with most recent or current.
Name - Child / Juvenile / Name of Placement / Type of Placement / Begin Date / End Date

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VI. / Other Placement Services
Include name of placement and dates, beginning with most recent or current.
Name - Child / Juvenile / Name of Placement / Type of Placement / Begin Date / End Date

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VII. / Objectives of the Treatment or Case Plan for the Child / Juvenile and Family
Address each child / juvenile when providing information for each of the following statements.
A. / Assessment of the risks to the physical safety and physical health of the child / juvenile or the community.
B. / Description of the plan for controlling identified risks.
C. / Statement of objectives of the plan, including any desired behavior changes of the child / juvenile, parents, or expectant mother.
VIII. /

Services Recommended

Name / Specific Service or Continuum of Services (including identification of the person for whom the service will be provided). / Person or Agency Primarily Responsible for Each Identified Service
A. / Availability and Funding of Specific Services
If the agency is recommending that the court order the child(ren)’s / juvenile(s)’s parent, guardian, or legal custodian or the expectant mother to participate in mental health treatment, anger management, individual or family counseling, or parent or prenatal development training and education, include a statement describing the availability of and funding for those services.
B. / Integrated Services Plan
Yes No / If child / juvenile is adjudged to be CHIPSCHIPS / JIPSCHIPS / JIPS / DelinquentDelinquentJIPSJIPS / Delinquent, should the child(ren) / juvenile(s) receive an integrated service plan under ss. 48.33(1)(c), 48.345(6m), 938.33(1)(c) or 938.34(6m) if available in the county?
If Yes, applies to:
If No, applies to:
C. / Educational Services
Description of academic and vocational skills needed by each child.
Yes No / Have educational needs / objectives been identified for each child / juvenile?
If Yes, complete this section. If No, go to Section VIII.
Description of plan for provision of educational services for each child / juvenile:
Yes No / Has the plan for each child / juvenile been discussed with appropriate school staff?
If No, justify:
Yes No / Is an Individualized Education Plan (IEP) currently in place for each child / juvenile?
Name - Child / Juvenile / Name - Current School / Current Grade Level
IX. / Dispositional Recommendation(s)
The child(ren) / juvenile(s) should be maintained in his / her / their home.
Applies to:
The child(ren) / juvenile(s) should be maintained in his / her / their current out-of-home placement.
Applies to:
The child(ren) / juvenile(s) should be placed outside of his / her / their home in:
Home of a relative
Applies to:
Home of a person not required to be licensed (if placement is for less than 30 days)
Applies to:
Foster home (Name and address if known and if identification will not present an imminent risk.)
Applies to:
Treatment foster home (Name and address if known and if identification will not present an imminent risk.)
Applies to:
Group home
Applies to:
Residential care center
Applies to:
Independent living situation
Applies to:
Describe living situation including names of other residents, address, etc.
Secure detention facility / juvenile portion of a county jail
Applies to:
Type 2 child caring institution
Applies to:
Serious juvenile offender program*
Applies to:
Secured group home**
Applies to:
Secured child caring institution**
Applies to:
Secured correctional facility**
Applies to:
Other - Specify:
Name - Child / Juvenile / Name of Proposed Placement Provider / Address (Street, City, State, Zip Code)
* / If juvenile is adjudicated delinquent for offense for which he / she may be placed in a serious juvenile offender program, include an analysis of the juvenile's suitability for placement in the serious juvenile offender program, in a secured correctional facility, in a secured group home, in an out-of-home care placement, or in his or her home and a recommendation as to the type of placement for which the juvenile is best suited:
** / Provide a brief justification for selecting these more restrictive placements, including a brief description of any less restrictive alternatives that are available and have been considered and why they have been determined to be inappropriate:
If it is recommended that the child(ren) / juvenile(s) be placed outside of his / her / their home, provide child / juvenile-specific information for all items checked:
The agency attests that remaining in his or her home is contrary to the welfare of the child / juvenile or the community because:
The agency attests that it has made reasonable efforts to prevent the removal of the child / juvenile from his or her home and that these reasonable efforts included:
The agency attests that reasonable efforts to prevent removal were not possible because:
The agency attests that it has made reasonable efforts to achieve the goal of the permanency plan and that these reasonable efforts included:
The agency recommends that the court find that reasonable efforts to reunify the child / juvenile with his or her family not be required because:
The parent has subjected the child / juvenile to aggravated circumstances, specifically:
The parent has been convicted of a specified offense against his or her child, specifically:
The parent's rights to another child have been involuntarily terminated, specifically:
The parent has relinquished custody of this child under s. 48.195.
The agency recommends that the court inform the parent(s) of any grounds for termination of parental rights that may be applicable and of the conditions necessary for the child / juvenile to be returned home or for the parent to be granted visitation (see below).
Legal custody of the child / juvenile should be transferred to:
If legal custody is currently with the child’s / juvenile’s parent, the agency attests that there is no less drastic alternative to transferring legal custody and that transferring legal custody to a relative has been considered.
The child / juvenile should be placed under the supervision of:
Length of Order
X. / Juvenile's Version of Offense and Effect on Victim of Delinquent Act
Not applicable
Address each juvenile individually when completing the statements in this section.
A. / Juvenile's version of offense:
B. / Victim(s)’s Statement(s):
C. / Describe any financial, physical, or psychological effects on the victim.
D. / Yes No Is restitution recommended?
If Yes, list juvenile and amount:
Describe the juvenile's ability to pay the recommended amount and the rationale for requiring the restitution.
XI. / Specific Rules of Supervision for the Juvenile (Check appropriate box)
Not applicable
See attached Rules of Supervision
Rules of supervision are the following (Address each juvenile individually when documenting rules of supervision):
XII. / Permanency Plan and Permanence Goal
Not applicable; child(ren) / juvenile(s) is / are not in out-of-home care.
Yes No / Is the permanency plan attached to this court report?
If Yes, go to Section XIII. If No, complete Section XII.
A. / Permanency Plan
The permanency plan has not yet been developed but will be provided to the court within sixty (60) days after child’s / juvenile’s removal from his or her home.
A permanency plan is not required per s. 48.38(3) or 938.38(3)(a) or (b).
B. / Permanence Goal
The permanence goal has not yet been established but will be included in the permanency plan and submitted to the court.
The permanence goal for this child / juvenile is:
Name - Child / Juvenile / Permanence Goal

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C. / Concurrent Permanence Goal
No concurrent permanence goal has been established at this time
The concurrent permanence goal for this child / juvenile is:
Name - Child / Juvenile / Concurrent Permanence Goal

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XIII. /

Visitation / Family Interaction Plan

/ See attached / See below
Include specific references to parents, all children, siblings, and other relatives, and whether the visitation / family interaction plan involves supervised or unsupervised visits or interactions.
XIII. / Conditions
Include specific measurable and behaviorally-quantifiable conditions that must be met by any of the parties before the case will be closed or the child(ren) / juvenile(s) will be reunified with his / her / their family.
XIV. / Child Support Recommendation
Support by the custodial parent(s) shall be set as a fixed amount based on the appropriate percentage of current gross income or, if no income, minimum wage. Support by the non-custodial parent shall be pursuant to any existing family court order. If there is no family court order in place, then support shall be set as a fixed amount based on the appropriate percentage of current gross income or, if no income, minimum wage. All support set should be expressed as a temporary order and the matter should be referred to the County Child Support Agency for further assessment of the parent’s / parents’ ability to contribute toward the cost of the child's care. Both parents shall provide a completed financial disclosure statement to the County Child Support Agency within thirty (30) days after the dispositional hearing. Both parents shall cooperate with the County Child Support Agency including, but not limited to, making all scheduled appointments, signing releases of information, and providing appropriate financial statements and records.
The may also bill both parents for post-dispositional services, placements, and sanctions.
XV. / Signatures
Name - Worker
SIGNATURE - Worker / Date Signed
Name - Supervisor
SIGNATURE - Supervisor / Date Signed

Original Disposition Report to Court Page 2 of 5

CFS-2118 (Rev. 02/2008)