Free HOWARD CIRCUIT COURT - Indiana

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

D-PDR 10

__________________ COURT JUVENILE DIVISION PRE-DISPOSITIONAL REPORT
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)

1

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

D-PDR 10

Client/Parent Statement Client Statement:

Parent Statement:

Victim Impact Information Victim Statement:

Additional Information:

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: State: (Select One) Alternate Phone: Zip: Race:

2

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

D-PDR 10

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 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: Court: Cause Number: State: (Select One) Alternate Phone: Zip: Race:

(Select One) (Select One) (Select One) (Select One)

3

Approved: 08/08/08 Revised: 06/16/09 School Information School of the child's LEGAL SETTLEMENT (Home school district): School currently attending or last attended: Grade: School performance: Employment Information Employed: Yes No Employer: Other employment information: Health Information Physical Health Concerns: If yes, comments: Yes No Status: (Select One)

D-PDR 10

Mental Health Concerns: Diagnosis/comments:

Yes

No

Prescribed medications: Compliant: Yes No Comments:

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

4

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

D-PDR 10

FINANCIAL INFORMATION Financial Report required by IC 31-37-17-3 and 31-40-1-3 to assist in the determination as to the person's financial responsibility for services provided to the child or the person Mother: TYPE OF INCOME Earned Income Child Support Order payee (list children) Retirement/Pension Social Security/SSI Other unearned income: Father: TYPE OF INCOME Earned Income Child Support Order payee (list children) Retirement/Pension Social Security/SSI Other unearned income: Child: TYPE OF INCOME Earned Income Child Support Order payee (list children) Social Security/SSI Other unearned income: Others in home (including siblings): TYPE OF INCOME Earned Income Child Support Order payee (list children) Social Security/SSI Other unearned income: AMOUNT (hourly/weekly/monthly) AMOUNT (hourly/weekly/monthly) AMOUNT (hourly/weekly/monthly) AMOUNT (hourly/weekly/monthly)

5

Approved: 08/08/08 Revised: 06/16/09 Child Related Expenses Child care cost Child's share of health insurance Insurance Type Medicaid Private Insurer Amount Paid By

D-PDR 10

Additional Financial Information: Number of children in the home: Number of overnights for this child with non-custodial parent: 106 ­ 110 76 ­ 80 0 ­ 51 111 ­ 115 81 ­ 85 52 ­ 55 116 ­ 120 86 ­ 90 56 ­ 60 121 ­ 125 91 ­ 95 61 ­ 65 126 ­ 130 96 ­ 100 66 ­ 70 131 - 135 101 ­ 105 71 ­ 75 Additional Information: 136 ­ 140 141 ­ 145 146 ­ 150 151 ­ 155 156 ­ 160 161 - 165 166 ­ 170 171 ­ 175 176 ­ 180 181 ­ 183 184+

Additional Financial Information if Recommending Placement OWNER ASSETS CURRENT VALUE (Identify by Name) Checking Account Savings Account Motor Vehicle Life Insurance Other:

ADDITIONAL INFORMATION Home Environment Home and Neighborhood:

Home Adjustment:

Religious Orientation:

Social Orientation:

6

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

D-PDR 10

Prior Services & Adjustment Pending Disposition Other Agency Involvement/Prior Services Provided:

Adjustment during pendency of Action:

STATEMENT OF NEEDS Summary of Risk & Needs Assessments

EVALUATION & RECOMMENDATION IV-E Findings Reasonable Efforts/Best Interests (if DCS funded services are being requested) 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:

7

Approved: 08/08/08 Revised: 06/16/09 IV-E Findings Reasonable Efforts/Best Interests (if DCS funded services are being requested)

D-PDR 10

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:

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): Evaluation/Summary Evaluation: Adoption Placement with a Fit and Willing Relative

Dispositional Options Considered & Evaluation of Each Option:

Statement of DCS Concurrence/Alternative Recommendation

Probation Recommendation

RECOMMENDED BY: Juvenile Probation Officer

8