Free JV-290.ofm - California

JV-290
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: FOR COURT USE ONLY

CHILD'S NAME: HEARING DATE AND TIME: CASE NUMBER:

CAREGIVER INFORMATION FORM

To the current caregiver, preadoptive parent, community care facility, or foster family agency caring for the child: You may submit written information to the court and you may attend review and permanency hearings. You may use this optional form to provide written information to the court. Please type or print clearly in ink and submit the original and eight copies of the form to the court clerk's office at least five calendar days (or seven calendar days if filing by mail) before the hearing. Be aware that other individuals involved in the case have access to this information. See form JV-290-INFO for instructions on how to complete this form and file it with the court. 1. a. Child's name: b. Child's date of birth: 2. Caregiver Information (Answer only if you are a caregiver, skip #3.): a. Name of caregiver: b. Type of caregiver: Foster parent Relative Nonrelative extended family member years Legal guardian Other (specify): months. Preadoptive parent

c. Child's age:

c. The child has been living in my home for (specify):

3. Agency or Facility Information (Answer only if you are an Agency or Facility, skip #2.): a. Name of agency or facility: b. Address: c. Telephone number: d. Type of facility: Foster family agency Community care agency years Title: hours/week. Other (specify): e. The child has been placed with our agency/facility for (specify): current home for (specify): years months. f. Name of person completing form: months, and in the

g. Hours per week the person completing this form spends with the child (specify): h. The information on this form consists of (1) the observations and recommendations of the person filling out this form. (2)

the observations and recommendations of a group or team made up of the following individuals (specify):

4. Current Status of Child's Medical, Dental, and General Physical and Emotional Health There is no new or additional information since the last court hearing. a. There is new or additional information since the last court hearing, as follows (do not include the names of doctors): b.

Page 1 of 2 Form Approved for Optional Use Judicial Council of California JV-290 [Rev. October 1, 2007]

CAREGIVER INFORMATION FORM

Welfare and Institutions Code, §§ 366.21(c), (d); 16010(f)(3); Cal. Rules of Court, rule 5.534(m) www.courtinfo.ca.gov

JV-290
CHILD'S NAME:
CASE NUMBER:

5. Current Status of Child's Education a. There is no new or additional information since the last court hearing. There is new or additional information since the last court hearing, as follows (do not include the names of schools): b.

6. Child's Special Education Status a. The child is a special education student. Date of last Individualized Education Plan (IEP): b. The child is not a special education student. c. I do not know the child's special education status. 7. Current Status of Child's Adjustment to Living Arrangement a. There is no new or additional information since the last court hearing. b. There is new or additional information since the last court hearing, as follows:

8. Current Status of Child's Social Skills and Peer Relationships a. There is no new or additional information since the last court hearing. b. There is new or additional information since the last court hearing, as follows:

9 . Current Status of Child's Special Interests and Activities a. There is no new or additional information since the last court hearing. b. There is new or additional information since the last court hearing, as follows:

10. Other Helpful Information a. There is no new or additional information since the last court hearing. b. There is new or additional information since the last court hearing, as follows:

11. Recommendation for Disposition (Outcome) a. I have no recommendation for disposition (outcome). b. I am recommending the following disposition (outcome):

12.

If you need more space to respond to any section on this form, please check this box and attach additional pages. Number of pages attached:

Date:

(TYPE OR PRINT NAME) JV-290 [Rev. October 1, 2007]

(SIGNATURE OF CAREGIVER OR FACILITY/AGENCY STAFF PERSON WHO HAS COMPLETED THIS FORM)

CAREGIVER INFORMATION FORM

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