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QUESTIONNAIRE In order to determine whether or not the filing of a JIPS or CHIPS petition is appropriate, we require that specific information be provided. After completing this questionnaire, please return it to the Juvenile Intake Office. You can then request to schedule an intake inquiry, in order to review the matter with a juvenile intake worker. Please call 395-1304 in order to schedule the intake inquiry. If it is determined that the request for a petition is appropriate, the juvenile intake worker may use this information and make a referral to the District Attorney’s Office with a request for a petition to be filed. Lawyers in the District Attorney’s Office review all requests for a JIPS or CHIPS petition, and will make the final determination whether or not a petition is to be filed. Please answer all the questions thoroughly and include additional information on another sheet of paper if necessary. Child’s Name: Child’s Date of Birth: Child’s Address: Home Phone: School/Grade: Mother’s Name: Address: Father’s Name: Address: List all other household members, their age, and relationship to the child named above: 1. Describe the current situation with your child (include information related to your child’s behavior and attitude, also, include dates of specific incidents). ---PAGE BREAK--- 2. Please give any background information that may be helpful to showing how things have progressed to where they are today. Also, explain how the situation was dealt with in the past. 3. What steps have been taken at home to address the current situation with your child? 4. Has the family or your child ever been involved in counseling? IF so, with whom (Include the name of the counselor and the counseling agency), and when (include when counseling began and the number of sessions attended). Also, please indicate what issues were addressed and whether or not counseling was helpful. Additionally, if counseling has not been attempted, or if it has been discontinued, please indicate why. ---PAGE BREAK--- 5. Has your child ever been placed outside of your home, at a relative’s home or anywhere else? If so, please list the dates that your child has been out of the home, where your child was placed, and the reason for placement. 6. What are your goals for your child’s future, and what type of assistance do you expect to receive by making a request for a petition to court? Signature of person that completed this form: