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TM_sm07b_juvenil_justice_face_sheet_37

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					                                                              FACE SHEET
Initial Date                                       Six Month Review Date                           Closing Summary Date


JUVENILE IDENTIFYING INFORMATION
Name - Juvenile                                                                                             Birthdate - Juvenile

Address - Juvenile (Street, City, State, Zip Code)                                                          Telephone Number - Juvenile

Name - Juvenile's Therapist                                                Diagnosis

Medications


Physical Description - Juvenile
Height - Juvenile                      Weight - Juvenile                   Hair Color - Juvenile            Eye Color - Juvenile

Identifying Marks - Juvenile


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




Others Living in the Home
      Name                                                                                   Relationship




Face Sheet
CFS-2235-37 (Rev. 11/2009)
Social History


PLACEMENT INFORMATION
Name - Caretaker                                                                            Telephone Number - Caretaker

Address (Street, City, State, Zip Code)                                                     School

Agency / Social Worker                                                                      Placement Begin Date


SUPERVISION STATUS
Judge                                                                                  Case Type                       Case Number

Offense

Effective Date                                   Expiration Date                                   Case Extension

Victim                                                                     Restitution Amount                  Community Service Hours

Other

Judge                                                                                  Case Type                       Case Number

Offense

Effective Date                                   Expiration Date                                   Case Extension

Victim                                                                     Restitution Amount                  Community Service Hours

Other

Judge                                                                                  Case Type                       Case Number

Offense

Effective Date                                   Expiration Date                                   Case Extension

Victim                                                                     Restitution Amount                  Community Service Hours

Other




AGENCY REFERRALS / COURT HISTORY
Referral Type       Referral                 Reason                        Adjudication                    Disposition               Disposition
                     Date                                                 Offense / Type                                                Date


DETENTION PLACEMENTS
(Please note start dates / end dates / placements / reasons / outcomes)


SERVICES / SIGNIFICANT INFORMATION
(Please note referral dates / services / agencies / service dates / addresses / telephone numbers / actions / other)


SANCTIONS
(Please note date and type of sanction)


REVIEW / CLOSING SUMMARY

Face Sheet                                                                                                                            Page 2 of 2
CFS-2235-37 (Rev. 11/2009)

				
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