JUVENILE JUSTICE FACE SHEET
CLIENT FACE SHEET
|Case Opening Date |County |
| / / | |
| IDENTIFYING INFORMATION |
|Name - |Birthdate - |
| | |
|Address - (Street, City, State, Zip Code) |Telephone Number - |
| | |
|PARENT INFORMATION |
|Name - Mother Role: Biological Step Other |Birthdate - Mother |
| | |
|Address - Mother (Street, City, State, Zip Code) |Telephone Number - Mother |
| |Home: Work: - - |
|Significant Other - Mother |
| |
|Name - Father Role: Biological Step Other |Birthdate - Father |
| | |
|Address - Father (Street, City, State, Zip Code) |Telephone Number - Father |
| |Home: Work: - - |
|Significant Other - Father |
| |
|Siblings Living at Home |
| |Name |Birthdate |Age |
| | | / / | |
| |Name |Birthdate |Age |
| | | / / | |
| |Name |Birthdate |Age |
| | | / / | |
| |Name |Birthdate |Age |
| | | / / | |
| |Name |Birthdate |Age |
| | | / / | |
|Others Living in the Home |
| |Name |Relationship |
| | | |
| |Name |Relationship |
| | | |
| |Name |Relationship |
| | | |
| |Name |Relationship |
| | | |
| |Name |Relationship |
| | | |
|CURRENT PLACEMENT INFORMATION |
|Name - Caretaker |Telephone Number - Caretaker |
| | |
|Address (Street, City, State, Zip Code) |School |
| | |
|Agency / Social Worker |Placement Begin Date |
| | |
|OUT OF HOME PLACEMENT HISTORY |
|Name |Type |Start Date |End Date |Court Ordered/Voluntary |
| |
|SUPERVISION STATUS |
|Judge |Case Type |Case Number |
| | | |
|Offense |
| |
|Effective Date |Expiration Date |Restitution Amount |Community Service Hours |
| / / | / / |$ . | |
|Other |
| |
|AGENCY REFERRALS / COURT HISTORY |
|Referral Type |Referral |Reason |Adjudication |Disposition |Disposition |
| |Date | |Offense / Type | |Date |
| |
|SERVICES / SIGNIFICANT INFORMATION |
|(Please note referral dates / services / agencies / service dates / addresses / telephone numbers / actions / other) |
|CLOSING SUMMARY |
|Closing Date |
| / / |
|Closing Summary |
| |
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