TJPC-FS-02-08 Field Supervision Review of Child Family Case Plan by lfl12074

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									                                 REVIEW OF CHILD/FAMILY CASE PLAN
                                                       (Field Supervision)
 IDENTIFYING INFORMATION
 Chil d's Name:                                                      County:
 Chil d's Date of Birth:                                             Caseworker PID#:
 Projected Date of Release From Probati on:


 TITLE IV-E CANDIDACY: Please indicate below the tool or documentation that was used to determine if the juvenile is
 currently a candidate for foster care. The risk assessment must be one of the tools used, but may not be the only tool used.

  Social Investigation/History Report dated:                         Psychological Report dated:
  Risk Assessment dated:                                   Other (explain & date)
  Juvenile IS a foster care candidate. Based on the above information this juvenile has been determined to be (or
     continues to be) at imminent risk of removal fro m the home and placement into foster care, absent preventative pre-placement
     intervention services. If the services described in the follo wing case plan (particu larly in the med ical, safety/security,
     emotional/ mental health, and family services domains) are not effective, the plan will be removal of the juvenile fro m his/her
     home with placement into foster care.
 Describe below the current risk factors which place the juvenile at imminent risk of removal and placement into foster care. The
 description must include parental behaviors or actions (or lack of actions) which currently place the child at risk of harm.




  Juvenile IS NOT currently a foster care candidate.                Date determination was made:

 MEDICAL/DENTAL DOMAIN**
 NAMES & ADDRESSES OF CHILD'S CURRENT HEALTHCARE PROVIDERS
                           MEDICAL                                                              DENTAL
 Name:                                                               Name:
 Address:                                                            Address:
 City/State/ Zi p:                                                   City/State/ Zi p:
 Phone #:                                                            Phone #:
 Chil d’s current medicati ons (includi ng psychotropic meds):
 Indicate what medications are for:
 List any other i mportant medical information/concerns:
 Goal #1:
 Discussion of progress:


 Goal #2:
 Discussion of progress:

 SAFETY/SECURITY DOMAIN **
 Goal #1:
 Discussion of progress:


 Goal #2:
 Discussion of progress:

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FY 2010                                                                                                               TJPC-FS-02-08
 EDUCATIONAL DOMAIN
 NAME & ADDRESS OF CHILD’S CURRENT EDUCATIONAL PROVIDER
 Name:                                                                                     Phone #:
 Address:                                                      City/State/ Zi p:
 Chil d’s current grade level pl acement:
 Goal #1:
 Discussion of progress:


 Goal #2:
 Discussion of progress:

 EMOTIONAL (MENTAL/BEHAVIORAL HEALTH) DOMAIN **
 Goal #1:
 Discussion of progress:


 Goal #2:
 Discussion of progress:

 PREPARATION FOR ADULT LIVING/VOCATIONAL DOMAIN (if child is or will be 16 before next review)
 Goal #1:
 Discussion of progress:


 Goal #2:
 Discussion of progress:

 FAMILY SERVICES DOMAIN **
 Goal #1:
 Discussion of progress:


 Goal #2:
 Discussion of progress:

 LIST ANY *NEW NEEDS THAT MAY HAVE BEEN IDENTIFIED SINCE THE LAST PLAN/REVIEW AND
 THE INTERVENTIONS TO ADDRESS THOSE NEEDS
                                                                                             Person
              Goal / Need                                Interventi on                     Responsi ble    Ti me Frame
 1.
 2.
 3..
 4.
 *NOTE: New needs/goals listed here are to be moved to the appropriate domain at the next review.




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FY 2010                                                                                                   TJPC-FS-02-08
 PARTICIPATION IN DEVELOPMENT OF CASE PLAN & DISTRIBUTION
                                                                                                                  Other
                                              Chil d                          Family               Name:
 Date Notified

 Method of Notification
 Date of Participati on

 Date Copy Recei ved/ Mailed
 LEVEL OF SUPERVISION & PLAN OF CONTACT
 A. Level of Supervision:

 B. Is the current level of supervision still appropriate?                                                          Yes            No
     If the current level of supervision is no l onger appropri ate, indicate the appropriate level:

 C. Di d the JPO maintai n contact with the chil d and family at least monthly?                                     Yes            No
     If no, expl ain why not:


 D. The current plan of contact between the chil d and JPO is as follows (document frequency & method):




 ACKNOWLEDGEMENT
I, the undersigned have received a copy of the case plan review, understand the case plan review process and have been provided an
opportunity to participate in the development of the case plan review.


I understand that I may request a review or change of this plan or an evaluation of p rogress at any time. I may also request an
administrative review if I have a comp laint about the services being provided, the Juvenile Probation Depart ment or its staff.




 Signature of Juvenile                                                                                 Date




 Signature of Parent/Leg al Guardi an or Custodi an                                                    Date




 Signature of Probation Officer                                                                        Date




 Signature of Supervisor                                                                               Date

If any party has not or refuses to sign, explain why and document whether they were provided a copy of the case plan review.




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FY 2010                                                                                                                TJPC-FS-02-08

								
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