Child Support Specialty Court Participant Data Collection Form

Child Support Specialty Court Participant Data Collection Form

FY 2010-2011

Section A – Screening*

Section B – Accepted Participants’ Data for Each Phase

Section C – Criminal/Court Activity, Service Referrals, Incentives, and Sanctions

Section D – Discharge

*Section A must be completed for every screened potential participant, whether or not the screening information obtained results in the participant’s admission into child support specialty court.

Section A – Screening

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October 2010

Referral Source ______

Court ______

Payer Information

Last Name ______

First Name ______

CaseNumber(s)

______

Address ______
______
______

Race: African-American

Alaskan Native

Asian/Pacific Islander

Caucasian

Hispanic/Latino

Multi-racial

Native American

Other: ______

Gender : MaleFemale

Date of Birth ______

U.S. Citizen: YesNo

Referral Date ______

Screening Date______

Payer Information continued…

Current Marital Status:Married

Separated

Divorced

Widowed

Single

Housing:Rent

Own

None

Driver’s License Status:None

Revoked

Suspended

Valid

Driver’s License Number ______

Pending Driver’s License Changes: Yes

No

Case Code ______

Saving Account: YesNo

Bank Name ______

Checking Account:YesNo

Bank Name ______

Payer’s Information Continued…

Health Insurance Type:Private

Medicare

Medicaid

None

Other

Insurer: ______

Number covered by Payer’s health insurance including Payer ______

History of Substance Abuse: YesNo

History of Mental Illness:YesNo

Highest Education Completed:

< or = 11th grade

GED

High School Graduate

Some Trade School

Trade School Graduate

Some College

College Graduate 2 year

College Graduate 4 year

Some Post Graduate

Advanced Degree

Currently in School? YesNo

Employment:Unemployed

Part-Time ≤ 35 hr/wk

Full-Time > 35 hr/wk

Not in Labor Force

Primary Occupation:Agricultural

Industrial

Clerical/Sales

Machine Trade

Miscellaneous

Processing

Professional

Service

Construction

Other______

Professional Licenses Held ______

Payer’s Information Continued…

Primary Support:Disability ______

Family

Retirement

Wages

Social Security

Veteran’s Benefits

Welfare

Worker’s Comp.

None

Other______

Gross Monthly Income ______

Seasonal Variation in Income?: YesNo

Pending Charges: YesNo

If yes, charge: ______

Bench Warrant: YesNo

If yes, reason: ______

Prior Convictions: YesNo

If yes, # misdemeanors ______

If yes, # felonies ______

Currently on Probation/Parole? YesNo

If yes, where?______

For what?______

Completion Date ______

PPO or Restraining Order?: YesNo

History of Domestic Violence?: Yes No

Child Protective Services History?:Yes

No

Total Child Support Obligation ______

Total Child Support Arrearage ______

Payer’s Information Continued…

Percent of Total Child Support Obligation Paid in Previous Three Months: (circle)

0%

10%

25%

50%

75%

100%

Reconciled with Parent

Formula Deviation?: YesNo

Private Collection Agency Involved? Yes

No

Date of Current Child Support Order(s)

______

Date(s) Last Modified ______

Default Order ______

Utilized ADR Services?: YesNo

CASE 1 ______

Payer’s Children

Child #1

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage ______

Payer’s Children continued…

Child #2

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

Payer’s Children continued…

Child #3

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

Payer’s Children continued…

Child #4

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to contact ______

Child Support Obligation ______

Child Support Arrearage______

CASE 2 ______

Payer’s Children continued…

Child #1

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

Payer’s Children continued…

Child #2

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

Payer’s Children continued…

Child #3

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

Payer’s Children continued…

Child #4

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

CASE 3 ______

Payer’s Children Continued…

Child #1

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

Payer’s Children continued…

Child #2

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

Payer’s Children continued…

Child #3

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

Payer’s Children continued…

Child #4

Last Name ______

First Name ______

Address ______

______

Age ______

Custodial Parent

Last Name ______

First Name ______

Address ______

Recipient of support, if not custodial parent ______

Dependent of Payer? YesNo

Custody Status ______

Parenting Time in Preceding 3 Months:

Ordered: Exercised:

None______

Less than monthly______

Monthly ______

Bi-weekly ______

Weekly______

Daily ______

Increased Contact Desired? YesNo

Barriers to Contact ______

Child Support Obligation ______

Child Support Arrearage______

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October 2010

Other Child Support Information

Children with Special Needs? Yes No

If yes, what kind? ______

Notes:

______

Acceptance Date: ______

Rejection Date: ______

Rejection Reason: ______

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October 2010

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October 2010

Section B - Accepted Participant’s Information

Payer’s Name ______Court ______Phase # _____

Number of Court Review Hearings This Phase: _____

Changes to Custody During this Phase for Any Children?: YesNo

If yes, what kind?______

Percent of Total Child Support Parenting Time Changesfor any Case 1 Children?

Obligation Paid This Phase: IncreasedDecreased

0%Parenting Time Changes for any Case 2 Children?

10%IncreasedDecreased

25%Parenting Time Changes for any Case 3 Children?

50%IncreasedDecreased

75%

100%

Reconciled with Parent

Change to Child Support Obligation? If so, current total obligation ______

If Payer Has a Substance Abuse Disorder

Number of Drug Tests Given: ______

Number of Positive Drug Tests ______and Number of Missed Tests _____

Drug of Choice ______

Treatment Modality: Outpatient Detoxstart date ______end date ______

Sub-Acute Detoxstart date ______end date______

Residentialstart date ______end date ______

Intensive Outpatientstart date______end date______

Outpatientstart date______end date______

Early Interventionstart date______end date______

If Payer Has a Mental Illness

DSM-IV Diagnosis ______

Treatment Modality:

Assertive Community Treatment start date____ end date______

Case Management/Support Coordinationstart date____ end date______

Co-Occurring Treatment Servicesstart date_____end date______

Community Based Servicesstart date_____end date______

Crisis Residential/Intensive Crisis Stabilization start ______end date______

Doctor/Medication Reviewstart date_____end date______

Employment Servicesstart date_____end date______

Inpatient Hospitalization/Partial Day Hospitalization start___end date_____

Residentialstart date______end date_____

Therapy Servicesstart date______end date_____

Number of Incentives Given in this Phase ______Tether Days in this Phase ____

Number of Sanctions Given in this Phase ______Jail Days in this Phase ______

Section B - Accepted Participant’s Information

Payer’s Name ______Court ______Phase # _____

Number of Court Review Hearings This Phase: _____

Changes to Custody During this Phase for Any Children?: YesNo

If yes, what kind?______

Percent of Total Child Support Parenting Time Changes for any Case 1 Children?

Obligation Paid This Phase:IncreasedDecreased

0%Parenting Time Changes for any Case 2 Children?

10%IncreasedDecreased

25%Parenting Time Changes for any Case 3 Children?

50%IncreasedDecreased

75%

100%

Reconciled with Parent

Change to Child Support Obligation? If so, current total obligation ______

If Payer Has a Substance Abuse Disorder

Number of Drug Tests Given: ______

Number of Positive Drug Tests ______and Number of Missed Tests _____

Drug of Choice ______

Treatment Modality: Outpatient Detox start date ______end date ______

Sub-Acute Detoxstart date ______end date______

Residentialstart date ______end date ______

Intensive Outpatientstart date______end date______

Outpatientstart date______end date______

Early Interventionstart date______end date______

If Payer Has a Mental Illness

DSM-IV Diagnosis ______

Treatment Modality:

Assertive Community Treatment start date____ end date______

Case Management/Support Coordinationstart date____ end date______

Co-Occurring Treatment Servicesstart date_____end date______

Community Based Servicesstart date_____end date______

Crisis Residential/Intensive Crisis Stabilization start ______end date______

Doctor/Medication Reviewstart date_____end date______

Employment Servicesstart date_____end date______

Inpatient Hospitalization/Partial Day Hospitalization start___end date_____

Residentialstart date______end date_____

Therapy Servicesstart date______end date_____

Number of Incentives Given in this Phase ______Tether Days in this Phase ____

Number of Sanctions Given in this Phase ______Jail Days in this Phase ______

Section B - Accepted Participant’s Information

Payer’s Name ______Court ______Phase # _____

Number of Court Review Hearings This Phase: _____

Changes to Custody During this Phase for Any Children?: YesNo

If yes, what kind?______

Percent of Total Child Support Parenting Time Changes for any Case 1 Children?

Obligation Paid This Phase: IncreasedDecreased

0%Parenting Time Changes for any Case 2 Children?

10%IncreasedDecreased

25%Parenting Time Changes for any Case 3 Children?

50%IncreasedDecreased

75%

100%

Reconciled with Parent

Change to Child Support Obligation? If so, current total obligation ______

If Payer Has a Substance Abuse Disorder

Number of Drug Tests Given: ______

Number of Positive Drug Tests ______and Number of Missed Tests _____

Drug of Choice ______

Treatment Modality: Outpatient Detox start date ______end date ______

Sub-Acute Detoxstart date ______end date______

Residentialstart date ______end date ______

Intensive Outpatientstart date______end date______

Outpatientstart date______end date______

Early Interventionstart date______end date______

If Payer Has a Mental Illness

DSM-IV Diagnosis ______

Treatment Modality:

Assertive Community Treatment start date____ end date______

Case Management/Support Coordinationstart date____ end date______

Co-Occurring Treatment Servicesstart date_____end date______

Community Based Servicesstart date_____end date______

Crisis Residential/Intensive Crisis Stabilization start ______end date______

Doctor/Medication Reviewstart date_____end date______

Employment Servicesstart date_____end date______

Inpatient Hospitalization/Partial Day Hospitalization start___end date_____

Residentialstart date______end date_____

Therapy Servicesstart date______end date_____

Number of Incentives Given in this Phase ______Tether Days in this Phase ____

Number of Sanctions Given in this Phase ______Jail Days in this Phase ______

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October 2010

Section B - Accepted Participant’s Information

Payer’s Name ______Court ______Phase # _____

Number of Court Review Hearings This Phase: _____

Changes to Custody During this Phase for Any Children?: YesNo

If yes, what kind?______

Percent of Total Child Support Parenting Time Changes for any Case 1 Children?

Obligation Paid This Phase: IncreasedDecreased

0%Parenting Time Changes for any Case 2 Children?

10%IncreasedDecreased

25%Parenting Time Changes for any Case 3 Children?

50%IncreasedDecreased

75%

100%

Reconciled with Parent

Change to Child Support Obligation? If so, current total obligation ______

If Payer Has a Substance Abuse Disorder

Number of Drug Tests Given: ______

Number of Positive Drug Tests ______and Number of Missed Tests _____

Drug of Choice ______

Treatment Modality: Outpatient Detox start date ______end date ______

Sub-Acute Detoxstart date ______end date______

Residentialstart date ______end date ______

Intensive Outpatientstart date______end date______

Outpatientstart date______end date______

Early Interventionstart date______end date______

If Payer Has a Mental Illness

DSM-IV Diagnosis ______

Treatment Modality:

Assertive Community Treatment start date____ end date______

Case Management/Support Coordinationstart date____ end date______

Co-Occurring Treatment Servicesstart date_____end date______

Community Based Servicesstart date_____end date______

Crisis Residential/Intensive Crisis Stabilization start ______end date______

Doctor/Medication Reviewstart date_____end date______

Employment Servicesstart date_____end date______

Inpatient Hospitalization/Partial Day Hospitalization start___end date_____

Residentialstart date______end date_____

Therapy Servicesstart date______end date_____

Number of Incentives Given in this Phase ______Tether Days in this Phase ____

Number of Sanctions Given in this Phase ______Jail Days in this Phase ______

Section C: In-Program Criminal or Court Activity

Payer’s Name ______Court ______

Charged During Program Participation? YesNo

If yes, charge ______

Occurred during phase # ______

Arrest date ______

Charge type:Felony

Misdemeanor

Civil

Petition

Other ______

Convicted? YesNo

If yes, Date ______

Sentence, if applicable ______

Program Impact:Discharged

Sanctioned

None

Other: ______

Bench Warrant Issued While in Program?:YesNo

If yes, Date ______

Reason ______

Occurred in Phase # ______

Services Referred to During Program

Service ______for ______Start date ______End Date ______

Service ______for ______Start date ______End Date ______

Service ______for ______Start date ______End Date ______

Service ______for ______Start date ______End Date ______

Service ______for ______Start date ______End Date ______

Service ______for ______Start date ______End Date ______

Service ______for ______Start date ______End Date ______

Service ______for ______Start date ______End Date ______

Incentives and Sanctions

Incentive Type ______Given For ______

Incentive Type ______Given For ______

Incentive Type ______Given For ______

Incentive Type ______Given For ______

Incentive Type ______Given For ______

Sanction Type ______Given For ______

Sanction Type ______Given For ______

Sanction Type ______Given For ______

Sanction Type ______Given For ______

Sanction Type ______Given For ______

Section D - Discharge from Child Support Specialty Court

Payer’s Name ______Court ______

Discharge Date ______

Discharge Reason:Successfully Completed

Absconded

Committed New Crime

Non-Compliant

Transferred to Another Jurisdiction

Death

Withdrew

Other: ______

Case Outcome:Sentence Reduced

No Change

Other: ______

Payer’s Employment Status at Discharge:Unemployed

Part-Time

Full-Time

Not in Labor Force

N/A

Payer’s Education Level at Discharge?: Currently in school? Yes No

< or = 11th grade

GED

High School Graduate

Some Trade School

Trade School Graduate

Some College

College Graduate 2 year

College Graduate 4 year

Some Post Graduate

Advanced Degree

Payer’s Mental Health Improved? YesNoN/A

Payer’s Substance Abuse Improved? YesNoN/A

Total Current Child Support Obligation at Discharge ______

Total Child Support Paid During Program ______

Total Current Arrearage ______

Percent of Total Child Support Obligation Paid in the Month Prior to Discharge:

0%

10%

25%

50%

75%

100%

Reconciled with Parent

Parenting Time Changes between Screening and Discharge

Case 1 Children

Increased Ordered Time for _____ child(ren)

Increased Exercised Time for ______child(ren)

Decreased Ordered Time for ______child(ren)

Decreased Exercised Time for ______child(ren)

No Change for ______child(ren)

Case 2 Children

Increased Ordered Time for _____ child(ren)

Increased Exercised Time for ______child(ren)

Decreased Ordered Time for ______child(ren)

Decreased Exercised Time for ______child(ren)

No Change for ______child(ren)

Case 3 Children

Increased Ordered Time for _____ child(ren)

Increased Exercised Time for ______child(ren)

Decreased Ordered Time for ______child(ren)

Decreased Exercised Time for ______child(ren)

No Change for ______child(ren)

***Please attach documentation indicating the payer’s current child support payments and arrearages from the Michigan Child Support Enforcement System (MICSES).

Notes: ______

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October 2010