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CASA INTAKE FORM

CHILD’S NAME:							CASE #:

DOB:	/	/		GENDER :	Male	Female	SOCIAL SECURITY #:		-	-

PRIMARY LANGUAGE:			English	Spanish	Asian Language		CHILD IS REMOVED FROM HOME: YES NO
PRIMARY LANGUAGE:			English	Spanish	Asian Language
			Arabic	Sign Language		Other	DATE REMOVED:	/		/
			Arabic	Sign Language		Other

RACE:
American Indian/Alaska Native	Asian/Asian-American
Black/African-American	Hispanic/Latino
Native Hawaiian/Other Pacific Islander
White	Other

CAREGIVER’s PHONE: (H) (		)	-

	(W) (	)	-
ADDRESS:
CITY/COUNTY:
STATE/ZIP:

TOTAL NUMBER OF PLACEMENTS PRIOR TO CASA:

#______

TOTAL NUMBER OF MONTHS IN PRIOR PLACEMENT(S):

#_____

PLACEMENT

Acute psychiatric facility Custody to other parent Custody with relative Detention

DJJ

Emergency shelter Foster home Group home Medical facility Own home father Own home mother Own home parents Relative foster care Relative placement Residential Therapeutic foster care Third party custody Runaway

(whereabouts unknown)

Short term diagnostic

Trial placement in home

COURT INFORMATION

OPEN DATE:

ASSIGNMENT DATE:

NAME OF CASA VOLUNTEER :

PETITION TYPE AT ASSIGNMENT:

ABUSE/NEGLECT

CHINS

CUSTODY/VISITATION

ENTRUSTMENT

RELIEF OF CUSTODY

OTHER

JUDGE:

COURT DATE:

GAL:

PHONE: (

)

COURT ORDERED VISITATION?

YES NO

LEGAL GUARDIAN/DSS SOCIAL WORKER

SUPERVISED VISITATION?

YES

NAME:

COURT APPROVED THE FOLLOWING NAMES FOR

PHONE:

(H) (

)

VISITATION:

ADDRESS:

(W) (

)

VISITATION SCHEDULE:

CITY/COUNTY:

DATE OF NEXT VISITATION:

STATE/ZIP:

MOTHER

FATHER

NAME:

PHONE:

(H) (

)

PHONE:

(H) (

)

(W) (

)

(W) (

)

ADDRESS:

CITY/COUNTY:

STATE/ZIP:

SIBLING

OTHER

NAME:

PHONE:

(H) (

)

PHONE:

(H) (

)

(W) (

)

ADDRESS:

(W) (

)

ADDRESS:

CITY/COUNTY:

STATE/ZIP:

ADDITIONAL CONTACTS

Social Worker/CPS:

PHONE: (W) (

)

FAX: (

)

Social Worker/Adoption:

PHONE: (W) (

)

FAX: (

)

Therapist:

PHONE: (W) (

)

FAX: (

)

After-School Program:

PHONE: (W) (

)

FAX: (

)

Mentor:

PHONE: (W) (

)

FAX: (

)

Other:

PHONE: (W) (

)

FAX: (

)

SCHOOL INFORMATION

Name of School:

Child’s Grade:

Principal:

PHONE: (W) (

)

FAX: (

)

Guidance Counselor:

PHONE: (W) (

)

FAX: (

)

Teacher:

PHONE: (W) (

)

FAX: (

)

Other:

PHONE: (W) (

)

FAX: (

)

DISABILITIES FOR CHILD

CONCERNS FOR CHILD/FAMILY

Autism

Absent parent

Developmental delay (0-9)

Aging out in foster care

Emotional disturbance

Behavior problem in caregiver household

Hearing impaired/deafness

Caregiver abused as child

Mental retardation

Caregiver housing instability

Multiple disabilities

Caregiver mental illness/personality disorder

Orthopedic impairment

Caregiver substance abuse

Other health impairment

Chronic Medical

Specific learning disability

CPS – Prior

Speech/language impairment

CPS – Current

Traumatic brain injury

CPS - Re-abuse

Visual impairment/blindness

Criminal involvement by child

Other

Criminal history – child

Criminal history – parent/caregiver

List services that the child is presently receiving:

Criminal history – household/family member

Death of parent(s)

Domestic violence in caregiver household

Drug addicted/drug exposed newborn

Economic instability

Exposed to domestic violence

Gang involvement

Has a teenage parent

Health and Hygiene issues for child

Health and Hygiene issues in caregiver household

Immigration Issues

Incarcerated parent

Is a teenage parent

Language barrier

Long time in foster care

Marital discord in caregiver household

Mental health concerns

List services that parent(s) is presently receiving:

Other

Parent has no healthy support system

Placement inappropriate

Placement instability

Psychotropic medication concerns

Removal/separation of siblings

Runaway

School-academic performance

School-behavioral

School-truant

Sexually abused

Sexual perpetrator

Siblings by multiple parents

Single primary caregiver

Substance abuse by child

Suicidal

Uncooperative parent

CASA Volunteer Tracking Form

Volunteer:				Date:
Number of cases:				Total number of children in case(s):
		NOTE: Use pages 2 & 3 for additional cases.
Case Number:				Next Court Date/Time:

Contacts		Name of Contact		Face to Face	Other	Total Time
(Actual Out of Court				(Dates)	(Telephone, etc.)	Spent with
Conversations/Meetings)					(Dates)	Each Contact

Child A

Child B

Child C

Child D

Mother

Father

Foster Parents

Social Worker

School

GAL

Daycare Provider

Supervisor

Other (therapist,
relatives, etc.)

Please List the Number of Hours Spent on Each of the Items Below:
Items	Hearings	Travel	Paperwork Publicity		In-service	Total Hours
		time			hours

Hours

List activities for in-service hours (include titles, dates and number of hours for each activity): 1.

CASA Volunteer Tracking Form (p. 2)

Volunteer:		Date:
Number of cases:		Total number of children in case(s):

Case Number:		Next Court Date/Time:

Contacts	Name of Contact	Face to Face	Other	Total Time
(Actual Out of Court		(Dates)	(Telephone, etc.)	Spent with
Conversations/Meetings)			(Dates)	Each Contact

Child A

Child B

Child C

Child D

Child E

Mother

Father

Foster Parents

Social Worker

School

GAL

Daycare Provider

Supervisor

Other (therapist,
relatives, etc.)

Notes:

	CASA Volunteer Tracking Form (p. 3)
Volunteer:		Date:
Number of cases:		Total number of children in case(s):

Case Number:		Next Court Date/Time:

Contacts	Name of Contact	Face to Face	Other	Total Time
(Actual Out of Court		(Dates)	(Telephone, etc.)	Spent with
Conversations/Meetings)			(Dates)	Each
				Contact
Child A

Child B

Child C

Child D

Child E

Mother

Father

Foster Parents

Social Worker

School

GAL

Daycare Provider

Supervisor

Other (therapist,
relatives, etc.)

Notes:

CASE CLOSURE INFORMATION

Case Name: _________________________________	Case #: ______________________________
CASA Volunteer: ____________________________	Date closed by court: ______/______/_________

Date closed by CASA program: _____/____/______ Date of Final/Permanent Placement: ____/____/_______

Court Closure Reasons

Adopted	CASA Relieved/Dismissed				Child AWOL		Child Death

Child/family moved out of area				Child turned 18		Denied - inappropriate referral
Denied - no volunteer		In compliance with Protective Order						Permanency Achieved

Removed from docket		Returned Home			Terminated Parental Rights
Transferred to another jurisdiction				Unable to reassign			Other:___________________________


Program Closure Reasons

Adopted	CASA Relieved/Dismissed				Child AWOL		Child Death

Child/family moved out of area				Child turned 18		Denied - inappropriate referral

Denied - no volunteer		In compliance with Protective Order						Permanency Achieved
Removed from docket		Returned Home			Terminated Parental Rights
Transferred to another jurisdiction				Unable to reassign			Other:___________________________


Final Placement at Closure
Adoptive placement		Custody to other parent				Custody with relative			Detention

DJJ	Emergency shelter		Final Adoption			Foster Home		Group home		Hospital
Independent Living Program				Own home father		Own home mother			Own home parents

Permanent Foster Care		Relative Foster Home				Relative placement			Residential
Runaway whereabouts unknown				Short Term Diagnostic			Therapeutic Foster Care

Third party custody		Other:__________________________________________________________

Was CASA’s permanent placement recommendation accepted?

Yes

Was the case worker permanent placement recommendation different?

Yes

Based upon the best professional assessment by the CASA program, was the Final Placement at

Program Closing a Safe - Permanent Home? Yes	No

Notes:

Docket #:__________________

CASA Case #:______________

Court Hearing Information Form


Case Name:_____________________________________________	CASA Volunteer:________________________________________
Date of Hearing:________________ Location of Hearing:______________________________		Report Submitted:	Yes	No
New Hearing Date(s):______________/_____________ Time(s):__________/___________ Judge:____________________________________
GAL:____________________________________________	DSS Worker:____________________________________________
Date Court Order Filed:____________________________	Date Court Order Received: _______________________________

Hearing Status:

Held

Continued

Continued in progress

Case Closed

Petition Type:

Hearing Types

Abuse/neglect

CHINS

Custody/Visitation

Entrustment

Relief of Custody

Other:_________________________________________________________________________________________

ERO	PRO		PPO	Adjudication	Entrustment	Expedited		Disposition	Review		Foster Care Review
Initial Perm Planning Hearing				2nd Perm Planning Hearing		Permanency Planning Hearing – subsequent					TPR Mother
TPR Father		Foster Care Review 12 month			Review of APPLA		Adoption Progress Review			Show Cause
Custody Visitation			CHINS	Appeals	Relief of Custody		Other:__________________________________________
Volunteer Recommendations:
Number of Recommendations
	Accepted:______________				[in full, in part, incorporated into the court order, or service plan, or directed by the judge]
	Rejected:______________				[use if the order is totally opposite the recommendation(s)]

No decision or not considered:______________

Is there a permanency plan?

Permanency Plan Type:

Yes

Adoption	APPLA	Continued Foster Care	Independent Living	Permanent Foster Care	Relative Placement
Return Home	Other:_______________________________________________________________________________________

Is there a concurrent plan in place?

Yes

List the concurrent plan:___________________________________________________________________________________________


Current Placement of Child(ren):
Acute Psychiatric Facility		Custody to other parent			Custody with relative		Detention		DJJ	Emergency shelter
Foster Home	Group home		Medical Facility		Other	Own home father		Own home mother			Own home parents
Relative foster care		Relative placement		Residential		Therapeutic Foster Care			Third party custody
Runaway whereabouts unknown			Short Term Diagnostic			Trial Placement in home			Trial placement own home

Trial placement other:______________________________________________________________________________________________

List those present at the hearing: _____________________________________________________________________________________

__________________________________________________________________________________________________________________

Court Ordered Visitation:

Yes

NoSupervised:

Yes

Docket #:__________________

CASA Case #:______________

Who will supervise?_________________________________________________________________________________________________

Visitation Schedule:_________________________________________________________________________________________________

Copy of the Court Order Obtained by CASA Volunteer?

Yes

Court Ordered Services for Child:

AA/NA

Ala-Non/Alateen

Anger management

Attachment Study

Background check on household member

Child support

Community support groups

Daycare/before and after-school programs

Dental care

Domestic violence program

Drug screening

Early childhood intervention assessment/services (age 0-3)

Economic/housing assistance

Education/vocation assistance

Employment

FAPT Review

Homestudy

Independent living

In-home services

Interpreter

Mediation

Medical care

Medication management

Mental health services

Mentor Parenting assessment

Parenting classes

Paternity testing

Psychiatric evaluation/services

Psychological evaluation

Sex offender evaluation/treatment

Special education services

Substance abuse services

Supervised visits

Therapeutic/appropriate placement

Tutoring/educational services

Other:_____________________________

Court Ordered Services for Mother:

AA/NA

Ala-Non/Alateen

Anger management

Attachment Study

Background check on household member

Child support

Community support groups

Daycare/before and after-school programs

Dental care

Domestic violence program

Drug screening

Early childhood intervention assessment/services (age 0-3)

Economic/housing assistance

Education/vocation assistance

Employment

FAPT Review

Homestudy

Independent living

In-home services

Interpreter

Mediation

Medical care

Medication management

Mental health services

Mentor Parenting assessment

Parenting classes

Paternity testing

Psychiatric evaluation/services

Psychological evaluation

Sex offender evaluation/treatment

Special education services

Substance abuse services

Supervised visits

Therapeutic/appropriate placement

Tutoring/educational services

Other:_____________________________

Court Ordered Services for Father:

AA/NA

Ala-Non/Alateen

Anger management

Attachment Study

Background check on household member

Child support

Community support groups

Daycare/before and after-school programs

Dental care

Domestic violence program

Drug screening

Early childhood intervention assessment/services (age 0-3)

Economic/housing assistance

Education/vocation assistance

Employment

FAPT Review

Homestudy

Independent living

In-home services

Interpreter

Mediation

Medical care

Medication management

Mental health services

Mentor Parenting assessment

Parenting classes

Paternity testing

Psychiatric evaluation/services

Psychological evaluation

Sex offender evaluation/treatment

Special education services

Substance abuse services

Supervised visits

Therapeutic/appropriate placement

Tutoring/educational services

Other:______________________________

Follow up on Services:

Start Date for Services: Child: ____________________________________________________________________________________________

Start Date for Services: Mother:___________________________________________________________________________________________

Start Date for Services: Father: ___________________________________________________________________________________________

Is anyone referred for services on waiting list? Child:	Yes	No	Mother:	Yes	No	Father:	Yes	No
Were any services completed at the time of this hearing? Child:		Yes	No	Mother:	Yes	No	Father:	Yes	No

Notes: ____________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Question	Answer
Form Name	Criminal Intake Form
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	criminal law intake form, DJJ, criminal client intake form, Homestudy

Criminal Intake Form – Fill Out and Use This PDF

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