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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