ORIGINAL DISPOSITION REPORT TO THE COURT, CFS-2329



ORIGINAL DISPOSITION REPORT TO THE COURT

Use of form: The information on this form conforms to the requirements of 48.33 and 938.33 Wis. Stats., and related statutes. It is mandatory under the terms of the State / County Contract and other provisions relating to the statewide automated child welfare information system. Personally identifiable information on this form will be used for identification purposes only.

|Name - Judge |Hearing Date (mm/dd/yyyy) |eWiSACWIS Case Number |

|      |      |      |

|Court Number |County |Case Type |

|      |      |      |

START_DYNAMIC_TABLE=ChildInfo

|      |

|Name (Last, First, MI, Suffix) |Birthdate |Age |

|      |      |      |

|Address (Street, City, State, Zip Code) |Telephone Number       |

|      |      |

|Current Caregiver |

|Name - Caregiver 1 (Last, First, MI, Suffix) |Name - Caregiver 2 (Last, First, MI) |Relationship to       |

|      |      |      |

|Address (Street, City, State, Zip Code) |Telephone Number       |

|      |      |

|Mother Unknown Deceased |

|Name (Last, First, MI) Status: Birth Adoptive |Birthdate |

|      |      |

|Address (Street, City, State, Zip Code) |Telephone Number       |

|      |      |

|Marital Status |Name - Spouse |

|  Married   Single   Widowed   Divorced |      |

|Father Unknown Deceased |

|Name (Last, First, MI, Suffix) |Birthdate |

|      |      |

|Address (Street, City, State, Zip Code) |Telephone Number       |

|      |      |

|Marital Status |Name - Spouse |

|  Married   Single   Widowed   Divorced |      |

|Status:   Adjudicated   Adoptive   Alleged   Presumptive |

END_DYNAMIC_TABLE=ChildInfo

|Tribal Information |

START_DYNAMIC_TABLE=TribalInfo

|Name:       |

|  Yes   No |Is the       an American Indian? |

| |If Yes, name of American Indian Tribe or Band:       |

END_DYNAMIC_TABLE=TribalInfo

| Yes No |If the above child(ren) / juvenile(s) is / are American Indian, has / have the Tribe(s) been notified of these proceedings? |

| |Verification of American Indian status provided by:       |

|I. |Jurisdiction | |

| |Include all 48.13 and 938.12 statutes and the proper subsection(s) that apply for each child / juvenile. |

| | | |

| |Name - Child / Juvenile |Jurisdiction |

| |      |      |

| |      |      |

| |      |      |

| |      |      |

| |      |      |

     

|II. |Agency's Recommended Finding |

| | | | | |

| |Name - Child / Juvenile |Agency’s Recommended Finding |

| |      | |

| |      | |

| |      | |

| |      | |

| |      | |

     

|III. |Description of Current Situation Regarding Child / Juvenile and Family |

| |Include names and living situation of all siblings. |

     

|IV. |Social History Narrative |

| |Describe the history of the family, important relatives, and others as appropriate to provide sufficient knowledge for the court to make informed decisions |

| |regarding the disposition, services, and conditions. Consider information related to previous agency referrals, family court history, relevant information |

| |about the child, siblings, parents and parent figures (including strengths, needs, history of prior services, etc.), family functioning, and professional |

| |evaluations / assessments. |

     

|V. |Placement History |

| |Include name of placement and dates, beginning with most recent or current. |

| |Name - Child / Juvenile |Name of Placement |Type of Placement |Begin Date |End Date |

START_DYNAMIC_TABLE=PlacementHistoryInfo

| |      |      |      |      |      |

END_DYNAMIC_TABLE=PlacementHistoryInfo

     

|VI. |Other Placement Services |

| |Include name of placement and dates, beginning with most recent or current. |

| |Name - Child / Juvenile |Name of Placement |Type of Placement |Begin Date |End Date |

START_DYNAMIC_TABLE=IHPlacementHistoryInfo

| |      |      |      |      |      |

END_DYNAMIC_TABLE=IHPlacementHistoryInfo

     

|VII. |Objectives of the Treatment or Case Plan for the Child / Juvenile and Family |

| |Address each child / juvenile when providing information for each of the following statements. |

| |A. |Assessment of the risks to the physical safety and physical health of the child / juvenile or the community. |

     

| |B. |Description of the plan for controlling identified risks. |

     

| |C. |Statement of objectives of the plan, including any desired behavior changes of the child / juvenile, parents, or expectant mother. |

     

|VIII. |Services Recommended |

| | | | |

| |Name |Specific Service or Continuum of Services (including |Person or Agency Primarily Responsible for Each Identified |

| | |identification of the person for whom the service |Service |

| | |will be provided). | |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

     

| |A. |Availability and Funding of Specific Services |

| | |If the agency is recommending that the court order the child(ren)’s / juvenile(s)’s parent, guardian, or legal custodian or the expectant mother to |

| | |participate in mental health treatment, anger management, individual or family counseling, or parent or prenatal development training and education, |

| | |include a statement describing the availability of and funding for those services. |

     

| |B. |Integrated Services Plan |

| | | Yes No |If child / juvenile is adjudged to be , should the child(ren) / juvenile(s) receive an integrated service plan under ss. |

| | | |48.33(1)(c), 48.345(6m), 938.33(1)(c) or 938.34(6m) if available in the county? |

| | | |If Yes, applies to: |      |

| | | |If No, applies to: |      |

| |C. |Educational Services |

| | |Description of academic and vocational skills needed by each child. |

     

| | | Yes No |Have educational needs / objectives been identified for each child / juvenile? |

| | | |If Yes, complete this section. If No, go to Section VIII. |

| | |Description of plan for provision of educational services for each child / juvenile: |

     

| | | Yes No |Has the plan for each child / juvenile been discussed with appropriate school staff? |

| | | |If No, justify: |

     

| | | Yes No |Is an Individualized Education Plan (IEP) currently in place for each child / juvenile? |

| | |Name - Child / Juvenile |Name - Current School |Current Grade Level |

| | |      |      |      |

     

|IX. |Dispositional Recommendation(s) |

| | |The child(ren) / juvenile(s) should be maintained in his / her / their home. |

| | |Applies to: |      |

| | |The child(ren) / juvenile(s) should be maintained in his / her / their current out-of-home placement. |

| | |Applies to: |      |

| | |The child(ren) / juvenile(s) should be placed outside of his / her / their home in: |

| | | |Home of a relative |

| | | |Applies to: |      |

| | | |Home of a person not required to be licensed (if placement is for less than 30 days) |

| | | |Applies to: |      |

| | | |Foster home (Name and address if known and if identification will not present an imminent risk.) |

| | | |Applies to: |      |

| | | |Treatment foster home (Name and address if known and if identification will not present an imminent risk.) |

| | | |Applies to: |      |

| | | |Group home |

| | | |Applies to: |      |

| | | |Residential care center |

| | | |Applies to: |      |

| | | |Independent living situation |

| | | |Applies to: |      |

| | | |Describe living situation including names of other residents, address, etc. |

     

| | | |Secure detention facility / juvenile portion of a county jail |

| | | |Applies to: |      |

| | | |Type 2 child caring institution |

| | | |Applies to: |      |

| | | |Serious juvenile offender program* |

| | | |Applies to: |      |

| | | |Secured group home** |

| | | |Applies to: |      |

| | | |Secured child caring institution** |

| | | |Applies to: |      |

| | | |Secured correctional facility** |

| | | |Applies to: |      |

| | | |Other - Specify: |      |

| | | |Name - Child / Juvenile |Name of Proposed Placement Provider |Address (Street, City, State, Zip Code) |

| | | |      |      |      |

     

| | |* |If juvenile is adjudicated delinquent for offense for which he / she may be placed in a serious juvenile offender program, include an analysis of |

| | | |the juvenile's suitability for placement in the serious juvenile offender program, in a secured correctional facility, in a secured group home, in |

| | | |an out-of-home care placement, or in his or her home and a recommendation as to the type of placement for which the juvenile is best suited: |

     

| | |** |Provide a brief justification for selecting these more restrictive placements, including a brief description of any less restrictive alternatives |

| | | |that are available and have been considered and why they have been determined to be inappropriate: |

     

| |If it is recommended that the child(ren) / juvenile(s) be placed outside of his / her / their home, provide child / juvenile-specific information for all items |

| |checked: |

| | |The agency attests that remaining in his or her home is contrary to the welfare of the child / juvenile or the community because: |

     

| | |The agency attests that it has made reasonable efforts to prevent the removal of the child / juvenile from his or her home and that these reasonable |

| | |efforts included: |

     

| | |The agency attests that reasonable efforts to prevent removal were not possible because: |

     

| | |The agency attests that it has made reasonable efforts to achieve the goal of the permanency plan and that these reasonable efforts included: |

     

| | |The agency recommends that the court find that reasonable efforts to reunify the child / juvenile with his or her family not be required because: |

     

| | | |The parent has subjected the child / juvenile to aggravated circumstances, specifically: |

     

| | | |The parent has been convicted of a specified offense against his or her child, specifically: |

     

| | | |The parent's rights to another child have been involuntarily terminated, specifically: |

     

| | | |The parent has relinquished custody of this child under s. 48.195. |

| | |The agency recommends that the court inform the parent(s) of any grounds for termination of parental rights that may be applicable and of the conditions |

| | |necessary for the child / juvenile to be returned home or for the parent to be granted visitation (see below). |

| | | |Legal custody of the child / juvenile should be transferred to: |

     

| | | |If legal custody is currently with the child’s / juvenile’s parent, the agency attests that there is no less drastic alternative to transferring |

| | | |legal custody and that transferring legal custody to a relative has been considered. |

| | |The child / juvenile should be placed under the supervision of: |

     

| | |Length of Order |

     

|X. |Juvenile's Version of Offense and Effect on Victim of Delinquent Act |

| | Not applicable |

| |Address each juvenile individually when completing the statements in this section. |

| |A. |Juvenile's version of offense: |

     

| |B. |Victim(s)’s Statement(s): |

     

| |C. |Describe any financial, physical, or psychological effects on the victim. |

     

| |D. | Yes No Is restitution recommended? |

| | |If Yes, list juvenile and amount: |      |

| |Describe the juvenile's ability to pay the recommended amount and the rationale for requiring the restitution. |

     

|XI. |Specific Rules of Supervision for the Juvenile (Check appropriate box) |

| | |Not applicable |

| | |See attached Rules of Supervision |

| | |Rules of supervision are the following (Address each juvenile individually when documenting rules of supervision): |

     

|XII. |Permanency Plan and Permanence Goal | |

| | Not applicable; child(ren) / juvenile(s) is / are not in out-of-home care. |

| | Yes No |Is the permanency plan attached to this court report? |

| |If Yes, go to Section XIII. If No, complete Section XII. |

| |A. |Permanency Plan |

| | |The permanency plan has not yet been developed but will be provided to the court within sixty (60) days after child’s / juvenile’s removal from |

| | |his or her home. |

| | | |A permanency plan is not required per s. 48.38(3) or 938.38(3)(a) or (b). |

| |B. |Permanence Goal |

| | |The permanence goal has not yet been established but will be included in the permanency plan and submitted to the court. |

| |The permanence goal for this child / juvenile is: | |

| | |Name - Child / Juvenile |Permanence Goal |

START_DYNAMIC_TABLE=PermanencyPlanInfo

| | |      |      |

END_DYNAMIC_TABLE=PermanencyPlanInfo

     

| |C. |Concurrent Permanence Goal |

| | |No concurrent permanence goal has been established at this time |

| |The concurrent permanence goal for this child / juvenile is: | |

| | |Name - Child / Juvenile |Concurrent Permanence Goal |

START_DYNAMIC_TABLE=ConcurPermPlanInfo

| | |      |      |

END_DYNAMIC_TABLE=ConcurPermPlanInfo

     

|XIII. |Visitation / Family Interaction Plan | See attached | See below | |

| |Include specific references to parents, all children, siblings, and other relatives, and whether the visitation / family interaction plan involves supervised or|

| |unsupervised visits or interactions. |

     

|XIII. |Conditions |

| |Include specific measurable and behaviorally-quantifiable conditions that must be met by any of the parties before the case will be closed or the child(ren) / |

| |juvenile(s) will be reunified with his / her / their family. |

     

|XIV. |Child Support Recommendation |

| |Support by the custodial parent(s) shall be set as a fixed amount based on the appropriate percentage of current gross income or, if no income, minimum wage. |

| |Support by the non-custodial parent shall be pursuant to any existing family court order. If there is no family court order in place, then support shall be set|

| |as a fixed amount based on the appropriate percentage of current gross income or, if no income, minimum wage. All support set should be expressed as a |

| |temporary order and the matter should be referred to the       County Child Support Agency for further assessment of the parent’s / parents’ ability to |

| |contribute toward the cost of the child's care. Both parents shall provide a completed financial disclosure statement to the       County Child Support Agency |

| |within thirty (30) days after the dispositional hearing. Both parents shall cooperate with the       County Child Support Agency including, but not limited to,|

| |making all scheduled appointments, signing releases of information, and providing appropriate financial statements and records. |

| | |

| |The       may also bill both parents for post-dispositional services, placements, and sanctions. |

|XV. |Signatures |

| | | | | |

| | | | | |

| |      | | | |

| |Name - Worker | | | |

| | | | | |

| | | | | |

| | | | | |

| |SIGNATURE - Worker | |Date Signed | |

| | | | | |

| | | | | |

| | | | | |

| |      | | | |

| |Name - Supervisor | | | |

| | | | | |

| | | | | |

| | | | | |

| |SIGNATURE - Supervisor | |Date Signed | |

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