Case Name:
Case Number:
Date of Shelter:
:
Child’s Name:
“All About Me” – Child Judicial Input Form
(Ages 9-12)
You are being asked for your input because a Judicial Review is being held regarding your case. It is very important that you be given an opportunity to be able to provide input about your case and to communicate with the Court. This form may be filed with the Court as an attachment to the Judicial Review Social Study Report/Case Plan Update.
LIVING SITUATION
How is your placement going? Is there anything about your placement that you would like the court to know? ______
Please tell the court about your daily routine (meals, chores, activities, bedtime and where you sleep). What are the rules in your current home? What happens if you break a rule?
______
Do you get money or an allowance? What are some of the reasons you get money or an allowance? Are you able to use your money to buy things? What do you like to buy?
______
Where do you wish you lived and with whom? Can you tell the Court why?
______
Do you feel safe? Why or why not?
______
VISITATION and CONTACT with FAMILY andFRIENDS
What kind of contact do you have with your parents and siblings(how often, where, how long)? Are the visits going well? Are there any changes you would like to ask for?
______
Do you have friends, family or other people(church leader, godmother or father, teachers) that you talk to and visit with? When do you get to talk and visit with them? Is there anyone else that you would like to have contact with?
______
SCHOOL and EXTRA-CURRICULAR ACTIVITIES
How are you doing in school? Do you feel that you are being provided with support you need to help you do well in school? If not, what do you feel you may need to help you be a success?
______
Please tell the court about your hobbies and activities? Are you able to participate in things that you did before you were placed in your current home? Are there activities you might want to become involved in?
______
What do you want to be when you grow up?
______
MORE THINGS TO THINK ABOUT
Do you have any needs that you would like to request (clothing, supplies, etc.)?
______
What is your greatest fear?
______
If you had three wishes, what would they be?
______
Is there anything else you would like the Court, your caseworker, your Guardian Ad Litem or your family to know?
______
Are there any papers you would like the Court to see(awards, report cards, letters, drawings)? Please attach them.
Please sign and return this form to your Family Care Manager or Child Protective Investigator. If additional space is required for your comments, additional pages may be attached.
______
Child’sSignatureCPI/Case Manager Signature
______
Date Date
ANOTHER PAGE IF YOU WOULD LIKE TO WRITE MORE
______
______
1 of 4