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DAWSON COUNTY JUVENILE COURT CHINS TRUANCY PANEL INTAKE QUESTIONNAIRE Page 1 of 4 JUVENILE’S INFORMATION NAME: CASE DOB: PLACE OF BIRTH: RACE: SEX (CIRCLE ONE) MALE / FEMALE ADDRESS: PRIMARY PHONE: CELL PHONE: WHO DOES JUVENILE RESIDE WITH HEALTH INSURANCE PROVIDER & POLICY SCHOOL ATTENDING: GRADE: SPECIAL EDUCATION STUDENT? YES / NO WHAT METHOD OF TRANSPORTATION DOES JUVENILE USE TO GET TO SCHOOL? (CIRCLE ONE) BUS RIDER CAR RIDER WALKS TO SCHOOL IF CAR RIDER, WHO NORMALLY DROPS OFF/ PICKS UP JUVENILE FROM SCHOOL: IS JUVENILE ENROLLED IN BEFORE OR AFTERSCHOOL CARE? BEFORE AFTER BOTH IF SO, WHERE: IS JUVENILE EMPLOYED? YES / NO IF SO, NAME AND PLACE OF EMPLOYMENT: PARENT/GUARDIAN/CUSTODIAN’S INFORMATION RELATIONSHIP TO JUVENILE: NAME: DOB: PLACE OF BIRTH: RACE: SEX: MALE / FEMALE MAIDEN NAME: ADDRESS: EMAIL ADDRESS: PRIMARY PHONE: CELL PHONE: EMERGENCY CONTACT NAME/RELATIONSHIP/PHONE NUMBER: PLACE OF OCCUPATION: EDUCATION: GRADE COMPLETED HIGH SCHOOL DIPLOMA GED SOME COLLEGE COLLEGE DEGREE MARITAL STATUS: SINGLE / MARRIED / DIVORCED ---PAGE BREAK--- DAWSON COUNTY JUVENILE COURT CHINS TRUANCY PANEL INTAKE QUESTIONNAIRE Page 2 of 4 PARENT/GUARDIAN/CUSTODIAN’S INFORMATION RELATIONSHIP TO JUVENILE: NAME: DOB: PLACE OF BIRTH: RACE: SEX: MALE / FEMALE MAIDEN NAME: ADDRESS: EMAIL ADDRESS: PRIMARY PHONE: CELL PHONE: EMERGENCY CONTACT NAME/RELATIONSHIP/PHONE NUMBER: PLACE OF OCCUPATION: EDUCATION: GRADE COMPLETED HIGH SCHOOL DIPLOMA GED SOME COLLEGE COLLEGE DEGREE MARITAL STATUS: SINGLE / MARRIED / DIVORCED SIBLINGS AND/OR OTHER PERSONS LIVING WITH YOUTH NAME DOB RELATIONSHIP TO CHILD 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) DOES YOUR FAMILY REQUIRE A TRANSLATOR? YES / NO DOES YOUR FAMILY HAVE RELIABLE TRANSPORTATION? YES / NO ---PAGE BREAK--- DAWSON COUNTY JUVENILE COURT CHINS TRUANCY PANEL INTAKE QUESTIONNAIRE Page 3 of 4 CURRENT SERVICES SCREENING The following information is being requested to better understand what services are currently in place for your child. The information will be important to the CHINS Truancy panel to allow the panel members to identify which services are already in place, to avoid recommending a duplicate service. Does this child currently have and IEP or 504 education plan in place, or is the child in the process of receiving an IEP or 504 education plan? (circle one) YES / NO Is this child currently involved in any extracurricular activities in school or outside of school? (circle one) YES / NO If yes, please provide the names of extracurricular activities that the child is involved with: Is your child attending any afterschool programs? YES / NO If yes, please provide the name of the afterschool program(s): Has your child had a recent in School Suspension (ISS) or Out of School Suspension due to behavior: YES ISS YES OSS NO Is your child currently expelled from school? YES Is getting to school a challenge? YES NO I CAR RIDER BUS RIDER Does your Child have challenges with or experienced challenges with any of the following? Reading Writing Speech Coping Skills Trauma Anxiety Depression Anger Respecting Authority at Home ___Respecting Authority at School ___School Attendance ___School Behavior Risky Behavior: Tobacco Risky Behavior: Other Risky Behavior: Alcohol Risky Behavior: Drugs Verbally Abusive Physically Abusive Mentally/ Emotionally Abusive Bullying Stealing Self-Harm ___Attempted Suicide NONE ---PAGE BREAK--- DAWSON COUNTY JUVENILE COURT CHINS TRUANCY PANEL INTAKE QUESTIONNAIRE Page 4 of 4 Is this child/family currently involved in an active Department of Family and Children Services (DFCS) Referral? (circle one) YES / NO If yes, please provide the name of the case manager: Does your child have any mental health challenges: YES NO If yes, what is the Child’s Diagnosis: Is this child currently being seen by a mental health professional? (circle one) YES / NO If yes, please provide the name of provider: Does your Child have any current or prior mental health hospitalizations? YES NO Name of Hospital and Length of Stay: Is the child receiving any current intensive/wrap around services: YES ___NO If so, what type: Do you feel that there is any information that the CHINS panel should be aware of regarding your child or the circumstances that led to this referral? (circle one) YES / NO