FACE TO FACE HOME VISIT FORM - DOC

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					                                                                                   Case Name:
                                                                                   Case Number:
                                                                                   Date of Shelter:



Child Name:

                                       “All About Me” – Child Judicial Input Form
                                                               (Ages 13-18)

You are being asked for your input because a Judicial Review is being held regarding your case. It is very important that you be given an
opportunity to be able to provide input about your case and to communicate with the judge. This form may be filed with the court as an
attachment to the Judicial Review Social Study Report/Case Plan Update.

                                                       LIVING SITUATION

How is your placement going? What do you like about your placement or would like to change? Do you feel safe?
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What is your daily routine (meals, chores, activities, bedtime & where you sleep)? What are the rules in your current home?
What happens if you break a rule?
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Do you receive an allowance? Are you able to use your allowance to buy things? What do you like to buy?
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Is there anything else about your placement that you would like the Court to know?
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Where do you wish you lived and with whom? Can you tell the court why?
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                    VISITATION and CONTACT with FAMILY, FRIENDS and OTHER LOVED-ONES

What kind of contact do you have with your parents and siblings (how often, where, how long)? What are some of
the things you do when at your visit?
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Are there any changes to visitation that you would like to request of the Court?
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                                                                        Case Name:
                                                                        Case Number:
                                                                        Date of Shelter:


Who else is important to you in your life (extended family, teacher, church leader, friend, boyfriend/girlfriend. etc)?
Do you have enough contact with these people? Do you know where they live and how to contact them?
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Do you have someone safe to turn to for support or when you need help? What are the kinds of support/help does
this person give you? What qualities does this person possess?
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                                SCHOOL & EXTRA-CURRICULAR ACTIVITIES

How are you doing in school? What are your favorite subjects? What subjects are difficult for you? Do you have
any special education needs?
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Are you receiving the supports you need to do well in school? What supports, if any, do you think you need to help
you be successful (tutor, staffing, supplies, preparation for SAT, FCAT, etc)?
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Is there anything else about your education/school setting that you would like the court to know?
___________________________________________________________________________________________________
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Are you involved in any extra-curricular or cultural activities and/or hobbies? What are they?
___________________________________________________________________________________________________
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What are some of the age-appropriate activities you wish to participate in that you might not be getting to do now or
have done in the past that you want to be doing?
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How do you like to spend your free time and who do you like to spend your free time with?
___________________________________________________________________________________________________
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                                                                             Case Name:
                                                                             Case Number:
                                                                             Date of Shelter:

                                              FUTURE PLANS AND GOALS

What goals/future plans do you have for yourself (employment, education, living)?
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What are some of the services/things/skills you need to reach your goals? Who do you have or need help from?
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If you are participating in Independent Living, what are some things you feel need to be included in your transition
plan to help you be successful in adulthood?
___________________________________________________________________________________________________
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Do you have any current needs that you would like to request? (clothing, supplies at home or school, health care needs, etc.)
___________________________________________________________________________________________________
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                                           MORE THINGS TO THINK ABOUT

What is your greatest fear? Are there any stressors which you are currently experiencing?
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If you had three wishes, what would they be?
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Additional comments or other things you would like the court, professionals and or your family to know:
___________________________________________________________________________________________________
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___________________________________________________________________________________________________

Are there any forms you would like to attach to this document for the court to see? (awards, report cards, drawings, letters)
Attach them.

Please sign and return this form to your Family Care Manager or Child Protective Investigator. If additional space
is required for your comments, additional pages may be attached.

___________________________________                                       ______________________________________
Youth’s Signature                                                         CPI/Case Manager’s Signature

___________________________________                                       ______________________________________
Date                                                                      Date


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                                                            Case Name:
                                                            Case Number:
                                                            Date of Shelter:

                        ADDITIONAL PAGE IF YOU WANT TO WRITE MORE

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