Document ID: 6397465
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STATE OF INDIANA
IN THE MATTER OF:
Child (Quest Person ID; Court Cause #)
Race: ; Sex: ; DOB ; Age:
Parent/Guardian (Quest Person ID; Court Cause #)
Race: ; Sex: ; DOB ; Age:
Parent/Guardian (Relationship of Child Name)
Current Placement:
Children Alleged to be in Need of Services
INTAKE OFFICER'S REPORT OF PRELIMINARY INQUIRY AND INVESTIGATION
NEXT HEARING DATE:
HAVE THE CHILDREN BEEN REMOVED FROM THE HOME? ; Removal date/time:
Prior to the removal, the children lived with: Parent/Guardian (Relationship of Child Name). The children were taken into custody with/without a court order.
PROBABLE CAUSE:
Date/time:
Location:
Facts and Evidence of Probable Cause:
A. Nature of Report:
B. Facts and Evidence:
C. Parent/Guardian/Custodian Response: Describe the parent/guardian/custodian response.
D. Children's Statement:
E. Other Pertinent Information:
SAID CHILD IS IN NEED OF SERVICES PURSUANT TO IC 31-34-1 IN THAT:
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Document ID: 6397465
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The children's physical or mental condition is seriously impaired or seriously endangered as a result of the inability, refusal, or neglect of the children's parent, guardian or custodian to supply the children with necessary food, clothing, shelter, medical care, education or supervision; (IC
31-34-1-1)
The children's physical or mental health is seriously endangered due to injury by the act or omission of the children's parent, guardian or custodian; (IC 31-34-1-2)
The children are the victim of a sex offense, or lives in the same household as another child who is the victim of a sex offense, under IC 35-42-4-1, IC 35-42-4-2, IC 34-42-4-3, IC 35-42-4-4, IC
35-42-4-7, IC 35-42-4-9, IC 35-45-4-1, IC 35-45-4-2 or IC 35-46-1-3; (IC 31-34-1-3)
The children's parent, guardian or custodian allows the children to participate in an obscene performance defined by IC 35-49-2-2 or IC 35-49-3-2; (IC 31-34-1-4)
The children's parent, guardian or custodian allows the children to commit a sex offense prohibited by IC 35-45-4; (IC 31-34-1-5)
The children substantially endangers the children's own health or the health of another; (IC 31-
34-1-6)
The children's parent, guardian or custodian fails to participate in a disciplinary proceeding in connection with the children's improper behavior, as provided for by IC 20-8.1-5.1-19 if the behavior of the children has been repeatedly disruptive in the school; (IC 31-34-1-7)
The children are missing as defined by IC 10-1-7-2; (IC 31-34-1-8)
The children are born with fetal alcohol syndrome or any amount of a controlled substance or legend drug in the children's body; (IC 31-34-1-10)
The children have an injury, has abnormal physical or psychological development, or is at a substantial risk of a life-threatening condition due to the mother's use of alcohol, a controlled substance, or a legend drug during pregnancy; (IC 31-35-1-11)
Special circumstances involving a disabled child who is deprived of life-sustaining nutrition or medical intervention necessary to remedy a life-threatening medical condition; (IC 31-34-1-9)
The child(ren) needs care, treatment, or rehabilitation that the children are not receiving and is unlikely to be provided or accepted without the coercive intervention of the Court.
FAMILY INFORMATION
Parent/Guardian
File Number:
Race: ; Sex: ; DOB: ; Age:
Ethnicity: ; Citizenship: ; Language:
Marital Status: ; Religion:
Address:
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Alias/Maiden Name:
Employment:
Known CPS History:
Parent/Guardian
File Number:
Race: ; Sex: ; DOB: ; Age:
Ethnicity: ; Citizenship: ; Language:
Marital Status: ; Religion:
Address:
Alias Name:
Paternity Established:
Employment:
Known CPS History:
CHILDREN'S HISTORY, HOME AND HEALTH Child
Legal custody of the child is with: Parent/Guardian (Relationship of Child Name) Pursuant to:
Others residing in the home: Parent/Guardian (Relationship of Child Name)
SIBLINGS:
Sibling Name (Relationship) - Age ; Address
Sibling Name (Relationship) - Age ; Address
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Is child placed in close proximity to HOME AND NEIGHBORHOOD?:
Is child able to maintain ESSENTIAL CONNECTIONS?:
School of the child’s LEGAL SETTLEMENT (Home School):
Does the child have an Individualized Educational Plan (IEP)? yes Are there special accommodations?
Name of School:
Grade in School:
CHILD'S PHYSICAL HEALTH (special need, accommodations and physical challenges):
CHILD'S MENTAL HEALTH (diagnosis, prescribed medication):
PRIOR DCS HISTORY FOR THE CHILD:
PRIOR COURT INVOLVEMENT (including JD/JS/CHINS/Informal Adjustments):
REASONABLE EFFORTS/BEST INTERESTS
Provide a description of family services available before the removal of the children and the efforts made to provide these services.
If removal was necessary, provide an explanation why these efforts did not prevent removal of the children.
It is in the best interests of the children to be removed from the home environment and remaining in the home would be contrary to the health and welfare of the children because:
RECOMMENDATION AND REASONING:
Filing of Petition alleging that the children are children in need of services. Out-of-home placement should be considered:
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Reasons for Recommendation:
ATTACHMENTS:
I affirm, under the penalties for perjury, that the foregoing representations are true.
Signature of Family Case Manager
Signature of DCS Supervisor
Family Case Manager
Indiana Department of Child Services
local office in County
Dated: Date of Report Creation
Supervisor
Indiana Department of Child Services
local office in County
https://168.214.204.105/equest/quest
8/17/2011