Free PROBATION OFFICER'S REPORT OF PRELIMINARY INQUIRY - Indiana

Approved: 08/08/08 Revised: 06/16/09

D-PI 3.05

PROBATION OFFICER'S REPORT OF PRELIMINARY INQUIRY (IC 31-37-8-2) STATE OF INDIANA __________________ COURT JUVENILE DIVISION
Date Prepared: Case No: In the Matter of: (a child alleged to be a Delinquent Child) Scheduled Court Date: Report Prepared By: Sources of Information: Juvenile's Personal Information Legal Name: Alias(es)/Nickname(s): Custodial Person(s) or Agency: Street Address: City: SSN: Race: State: (Select One) DOB: Gender: (Select) Zip: Age:

JUVENILE'S CURRENT STATUS Current Delinquent Act(s) Information CRIME OR CONDITION ALLEGED: Alleged Offense: I.C.: Alleged Offense: I.C.: Referring Agency: Custody Status: Co-Offender(s) Status/Case No: PARTICULARS OF: Date Committed: Class (if committed by an adult) Date Committed: Class (if committed by an adult)

(Select) (Select)

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Approved: 08/08/08 Revised: 06/16/09

D-PI 3.05

Detention Information Was the youth detained? If "yes", Date: Location: Reason for detention: Unlikely to Appear for subsequent hearings Child has committed an act that would be an A or B Felony Protection of the Child/Community Parent or Guardian cannot be located or unable/unwilling to take custody Child has reasonable basis for requesting to not be released Parent/Guardian notified of detention hearing (if applicable): (Select One) If unable to contact parent/guardian, describe the attempts made:

(Select One)
Time:

IV-E Findings Reasonable Efforts/Best Interests (if youth was detained) Provide a description of services available before the removal of the child and the efforts made to provide these services:

Provide an explanation why these efforts did not prevent removal of the child:

Explain why these efforts were reasonable:

The safety of the child precludes the immediate use of family services to prevent removal of the child because:

It is in the best interests of the child to be removed from the home environment and remaining in the home would be contrary to the health and welfare of the child because:

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Approved: 08/08/08 Revised: 06/16/09

D-PI 3.05

JUVENILE'S BACKGROUND Prior Legal History Date of Referral Charge(s) Case No. Disp. (Date/Type)

Family Information Mother's Name: DOB: Marital Status: Address: City: Home Phone: Employment: Known Criminal or DCS History: Father's Name: DOB: Marital Status: Address: City: Home Phone: Employment: Known Criminal or DCS History: Paternity Established: If yes: Yes No Unknown/NA By paternity affidavit By marriage at birth of this child By court order Court: Cause Number: State: (Select One) Alternate Phone: Zip: Race: State: (Select One) Alternate Phone: Zip: Race:

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Approved: 08/08/08 Revised: 06/16/09

D-PI 3.05

Other, if applicable: Relationship to child: DOB: Marital Status: Address: City: Home Phone: Employment: Known Criminal or DCS History: Siblings: Name Relationship Age Address Legal History (yes or no) (Select One) State: (Select One) Alternate Phone: Zip: Race:

(Select One) (Select One) (Select One) (Select One)
School Information School of the child's LEGAL SETTLEMENT (Home school district): School currently attending or last attended: Grade: Is the child classified as special education? School performance: Employment Information Employed: Yes No Employer: Other employment information: Health Information No Yes Status: (Select One) No

Physical Health Concerns: If yes, comments:

Yes

Mental Health Concerns: Diagnosis/comments:

Yes

No

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Approved: 08/08/08 Revised: 06/16/09

D-PI 3.05

Health Information Prescribed medications: Compliant: Yes No Comments:

Substance Abuse Information History of Usage: Yes Additional Information: No

EVALUATION & RECOMMENDATION Evaluation/Summary

Recommendation Preliminary Inquiry Recommendation: Dismissal Informal Adjustment File Petition Custody recommendation: Release to parent Electronic Surveillance Other Comments: Release to Guardian Shelter Care Home Detention Detention Center Referral to other agency Other

Recommendation if case proceeds to disposition:

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Approved: 08/08/08 Revised: 06/16/09

D-PI 3.05

Permanency Plan (if youth has been removed from the home or removal is being recommended) Plan (If more than one plan is identified, list plan in order of preference): Reunification Guardianship Another Planned Permanent Living Arrangement Estimated Date for Permanency Plan (one year from date of Preliminary Inquiry): Permanency Plan Court Hearing due date (one year from the date of removal): RECOMMENDED BY: Juvenile Probation Officer Adoption Placement with a Fit and Willing Relative

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