Free 49584.FH11 - Indiana

TAKING CUSTODY OF A CHILD WITHOUT A VERBAL OR WRITTEN COURT ORDER: DESCRIPTION OF CIRCUMSTANCES
State Form 49584 (R3 / 3-06) / CW 0018

This completed record is CONFIDENTIAL pursuant to IC 31-33-18-1. Pursuant to IC 31-34-2-6, the following information is provided as documentation of circumstances that resulted in taking a child who is believed to be a child in need of services into custody without a verbal or written court order.
Name(s) of child(ren) Name(s) of parent, guardian, or custodian Address of parent, guardian, or custodian (number and street, city, state, and ZIP code)

A. Facts establishing probable cause: I. Said child is believed to be a child in need of services pursuant to IC 31-34-1 in that: (check applicable section) 1. the child's physical or mental condition is seriously impaired or seriously endangered as a result of the inability, refusal, or neglect of the child's parent, guardian, or custodian to supply the child with necessary food, clothing, shelter, medical care, education or supervision; the child's physical or mental health is seriously endangered due to injury by the act or omission of the child's parent, guardian, or custodian; the child is the victim of a sex offense under IC 35-42-4-1, IC 35-42-4-2, IC 35-42-4-3, IC 35-42-4-4, IC 35-42-4-7, IC 35-42-49, IC 35-45-4-1, IC 35-45-4-2, or IC 35-46-1-3, or the law of another jurisdiction, including a military court, that is substantially equivalent to these Indiana codes; or the child lives in the same household as another child who is the victim of the same sex offenses described above; or the child lives in the same household as the adult who committed one of the same sex offenses, and it resulted in a conviction or a judgment under IC 31-34-11-2. the child's parent, guardian, or custodian allows the child to participate in an obscene performance as defined by IC 35-49-2-2, or IC 35-49-3-2; the child's parent, guardian, or custodian allows the child to commit a sex offense prohibited by IC 35-45-4; the child substantially endangers the child's own health or the health of another individual; the child's parent, guardian, or custodian fails to participate in a disciplinary proceeding in connection with the student's improper behavior, as provided for by IC 20-8.1-5.1-19, if the behavior of the student has been repeatedly disruptive in the school; or the child is a missing child (as defined in IC 10-1-7-2).

2. 3.

4. 5. 6. 7. 8.

II. Briefly describe the circumstances in which the child was found that warranted selection of the CHINS categories listed above.

B. Safety Assessment was completed. (check one) Yes No If yes, skip to C. If no, use the following format to describe how safety was assessed. I. Identify safety factors below by checking the behaviors or conditions that were present at the time the child(ren) was taken into custody. 1. 2. 3. 4. 5. Caregiver's behavior is violent or out-of-control. Caregiver describes or acts toward child in predominately negative terms or has extremely unrealistic expectations. * Caregiver caused serious physical harm to the child or has made a plausible threat to cause serous physical harm. Explanation for the injury is unconvincing. The family refuses access to the child, or there is reason to believe that the family is about to flee, or the child's whereabouts cannot be ascertained.

6. 7. 8. 9. 10. 11. 12. 13.

Caregiver has not, or cannot, or will not provide supervision necessary to protect child from potentially serious harm. Caregiver is unwilling, or is unable, to meet the child's immediate needs for food, clothing, shelter, and / or medical or mental health care. Caregiver has previously maltreated a child, and the severity of the maltreatment, or the caregiver's response to the previous incident(s), suggests that child safety may be an immediate concern. Child is fearful of caregiver(s), other family members, or other people living in or having access to the home. The child's physical living conditions are hazardous and immediately threatening. Child sexual abuse is suspected, and circumstances suggest that child safety may be an immediate concern. Caregiver's current drug or alcohol use seriously affects the caregiver's ability to currently supervise, protect, or care for the child. Other * (specify): __________________________________________________________________________________ * Should also be considered in combination with other credible evidence.

II. Briefly describe the specific individual's behaviors, conditions, and / or circumstances associated with all safety factors checked.

III. Possible controlling interventions other than removal of child(ren): 1. Use family resources, neighbors, or other individuals in the community as safety resources. 2. Use community agencies or services as safety resources. 3. Have the alleged perpetrator leave the home, either voluntarily or in response to legal action. 4. Have the non-maltreating caregiver move to a safe environment with the child. 5. Have the caregiver(s) place the child outside the home (formal voluntary placement). 6. Other: _____________________________________________________________________________________________________ Explain why controlling interventions 1-6 could not be used to keep the child(ren) safe, and describe your discussion with the caregiver(s) regarding the placement.

C. Explain what steps were taken to obtain a court order and why a verbal or written court order could not be obtained.

D. For probation officers and family case managers only. Explain why it was not possible to obtain the assistance of a law enforcement officer.

Signature of person taking custody Title Telephone number

Printed name of person taking custody Name of agency

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Address (number and street, city, state, and ZIP code)

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DISTRIBUTION: White - Local DCS office; Canary - Person taking custody