TM_REQUEST FOR EMERGENCY DETENTION OR PICK-UP …
Request for Temporary Physical Custody or Pick-Up Order
|Name - Worker |Telephone Number |County |Site / Zone |
| | | | |
|Court Number |
| |
|I. |Family Composition |
| |1. |CHIPS - List oldest child first. |
START_DYNAMIC_TABLE=DetainedChildInfo
| |
|Name (Last, First, MI) |Birthdate |Age |
| | | |
|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) |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=DetainedChildInfo
| |2. |List any other children who are part of this family but have not been taken into Temporary Physical Custody at this time. |
| | |This includes adult children, and children who have been previously involved in a termination of parental rights. |
| | |Name - Child |Birthdate |Address - Include Zip Code |
START_DYNAMIC_TABLE=NonDetainedChildInfo
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| |8. |What was the original cause for concern that led the Bureau to make contact and intervene? |
| |9. |Detailed description of the actions taken (TPC) to protect the child(ren) and why, including options considered to prevent removal (i.e. Danger threats |
| | |identified; options considered, available, appropriateness; caregiver involvement in the decision; and location of the children) |
| |10. |Summary of the incident based on Bureau contacts and information gathered (i.e. Who went out to gather information; who was observed, interviewed, over |
| | |what span of time; and what are the conclusions thus far regarding what happened, how it happened, explanations and attitudes of principle parties, |
| | |effects on the children?) |
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| |11. |Any pertinent history that supports the premise that the incident may not be an anomaly and/or the dangerous conditions are a pattern? |
| |12. |Information gathered thus far that helps understand more than the incident: (i.e. The general functioning of all the children; the general functioning |
| | |of all the adult caregivers; the general approach to and methods of discipline used; the general parenting by the adult caregivers; and other forms of |
| | |maltreatment that may be happening) |
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