Full Text
1 Douglas County Department of Health and Human Services Court Report Info Parent’s Report Appointment Child’s Birth Parents Home Address(if different):________ Telephone Insurance information: Parents attitude and opinion about child’s offense: PERSONAL HISTORY A. Youth under Consideration: Please check all that apply to the child: _____Active _____Doesn’t Follow Through _____Defiant of Authority _____Passive _____Generous _____Easygoing _____Loud _____Honest _____Suspicious _____Quiet _____Uncooperative _____Steals _____High Strung _____Poor Eating Habits _____Hard Worker _____Cooperative _____Happy _____Outgoing _____Affectionate _____Lies _____Withdrawn _____Sociable _____Fights(physical aggression) _____Loner _____Argues ---PAGE BREAK--- 2 Describe any and all behavior of the child within the home(follows home rules, curfew, respect authority, bizarre thoughts, suicidal tendencies, reckless, dangerous, runaway List any problems including illness or injury that your child had from: (please give age) 1. 0-5 years of 2. 5-11 years of 2. 12-17 years of Has your child ever been physically or sexually abused? If yes, please explain, list age__ Do you believe your child is using or abusing alcohol and/or drugs? Do not believe so Have heard so, or are suspecting Believe they are developing a problem Believe they have a problem What substance do you Has anyone else (school personnel, friends, other juveniles) indicated that your child has a drug or alcohol problem?_________ please ---PAGE BREAK--- 3 How often do you believe your child is using/or abusing substances? _____(less than 3 times/ month) times weekly) (3-5 times weekly) Daily Please describe your child’s behavior when using alcohol and/or drugs vs. not using:___ Names and addresses of child’s associates: Describe child’s behavior with and type of influence from What interests/hobbies does your child Has your child ever had a history of possessing weapons or firearms? Please Please describe all of your child’s aggressive patterns or tendencies (physical assaults, threats, damage to property, verbal aggression B. Education: Grade School Years (K-6) At what age did your child begin school?______ Did he/she ever have to repeat a grade? If yes, when and What was your child’s first reaction to school? _____Positive Negative ____Other (please ---PAGE BREAK--- 4 How long did this reaction What was his/her attitude towards teachers? _____Friendly _____Unfriendly Indifferent _____Fearful Strong dislike Other (please explain):________ Describe any and all behavior problems in grade school, list grade Junior High School Years (7-8) Did your child’s attitude toward school change during these years? ___Yes If yes, please Did your child receive any special education services during these Please describe any and all behavior problems in junior high school, list dates and grade What type of grades did your child receive in junior high school? A B C D F Contact with school: (current level of functioning, school’s perception of child, home Contact High School Years (9-12) Did your child’s attitude toward school change during these years? ___Yes If yes, please ---PAGE BREAK--- 5 Did your child receive any special education services during these Please describe any and all behavior problems in high school, list dates and grade What type of grades did your child receive in high school? A B C D F Contact with school: (current level of functioning, school’s perception of child, home Contact C. Medical and Health Please describe any and all medical/health concerns of your child (include allergies, hospitalizations, current needs etc…) give dates and D. Prior placements and services Has your child ever been placed outside the home? If yes, please give placements, and What kind of services has your child/ family received in the past/present, from whom?__ ---PAGE BREAK--- 6 E. & Has your child/family received services in the past? Please explain, list dates (i.e. individual/ family counseling, medications, mental health hospitalizations F. Employment and Financial Management Mother: Place of Father: Place of Step parent: (name)___________Place of Youth: of FAMILY A. Family Development Who lives in the juvenile's home? Name: Birthdate: Age: Relationship: What parent does the child reside with most of the time? (Please give name and address): Which parent is the child closest Describe the relationship between the child and parent(s) in the home: Mother/Step- ---PAGE BREAK--- 7 Describe the relationship between the child and absent parent(if applicable):__________ Describe the relationship between the child and siblings(in the Who does most of the discipline in the What methods work the What methods do not Please describe your ability to adequately supervise your child at home and in the What services do you feel are needed to best help your In what ways do you feel your child needs to What type of family activities does your child participate in, how If parents are divorced, what issues surrounded the ---PAGE BREAK--- 8 Parents Mother/Stepmother (Circle appropriate parent in the home) Health: Good_____ Average_____ Poor_____ Please list health Alcohol/Drug Problems?: Please Education Level: Grade School Only Some High School High School Diploma Some College Vo Tech Bachelor Graduate Degree Date of current marriage: Year_____ Dates of divorces or separations: Year_____ Year_____ Year_____ Military Experience: Branch of Father/Stepfather (Circle appropriate parent in the home) Health: Good_____ Average_____ Poor_____ Please list health Alcohol/Drug Problems?: Please ---PAGE BREAK--- 9 Education Level: Grade School Only Some High School High School Diploma Some College Vo Tech Bachelor Graduate Degree Date of current marriage: Year_____ Dates of divorces or separations: Year_____ Year_____ Year_____ Military Experience: Branch of Absent Natural Parent Health: Good_____ Average_____ Poor_____ Please list health Alcohol/Drug Problems? Please Education Level: Grade School Only Some High School High School Diploma Some College Vo Tech Bachelor Graduate Degree Date of current marriage: Year_____ Dates of divorces or separations: Year_____ Year_____ Year_____ ---PAGE BREAK--- 10 Military Experience: Branch of B. Home and neighborhood: Please describe the neighborhood you live Please describe your home(age, type, #of rooms/bedrooms, space, Worker Notes: ---PAGE BREAK--- 11 CHILD’S ATTITUDE AND VERSION OF OFFENSE What behavior did you engage in to get petitioned into Juvenile What were you thinking when your were engaging in the How do you think your behavior affected the What do you think you could do to show the victim that you are truly sorry for your behavior, and what could be done to repay the victim for their