Free COMPLAINT, NON-SCHOOL FAMILY WITH SERVICE NEEDS - Connecticut

COMPLAINT, NON-SCHOOL FAMILY WITH SERVICE NEEDS
JD-JM-120 Rev. 10-07 C.G.S. § 46b-120, 46b-149, 07-04, Spec. P.A. 07-4, Sec. 30

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STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS
www.jud.ct.gov

TO: The Superior Court , Juvenile Matters
ADDRESS OF COURT NAME OF CHILD NAME OF MOTHER MOTHER'S TELEPHONE NUMBERS: HOME: NAME OF FATHER FATHER'S TELEPHONE NUMBERS: HOME: NAME OF GUARDIAN, IF ANY GUARDIAN'S TELEPHONE NUMBERS: HOME: INDIAN TRIBE/RESERVATION, IF ANY WORK: SCHOOL/GRADE CELL: WORK: ADDRESS OF GUARDIAN CELL: WORK: ADDRESS OF FATHER CELL: ADDRESS OF CHILD ADDRESS OF MOTHER DOCKET NO. SEX DATE OF BIRTH

COMPLAINT The undersigned believes that the above family is a family with service needs because it includes said child who: ("X" appropriate box(es)) A. Has without just cause run away from his/her parental home or other properly authorized and lawful place of abode.
WHEN (Date) FOR HOW LONG TO WHERE (If known)

PREVIOUS HISTORY OF RUNNING AWAY

"X" here if the child has been missing for over twenty-four (24) hours at the time of this complaint "X" here if you have contacted the police and reported the child as missing. B. Is beyond the control of his/her parent(s), guardian or other custodian. (Describe behavior and date(s) of event(s))

C. Has engaged in indecent or immoral conduct. (Describe behavior and date(s) of event(s))

D. Is thirteen years of age or older and has engaged in sexual intercourse with another person and such other person is thirteen years of age or older and not more than two years older or younger than such child. ADDITIONAL INFORMATION
Please provide information regarding the following, if available:
CURRENT MENTAL HEALTH DIAGNOSES OF THE CHILD (If known) 1. HAS THE CHILD RECEIVED HELP FOR PROBLEM BEHAVIORS IN THE PAST?

NO NO NO NO

YES (when and where): YES (specify): YES (specify clinician's name): YES (specify dates and reasons):
(Continued on back/page 2)

2. DOES THE CHILD CURRENTLY TAKE ANY MEDICATIONS? 3. DOES THE CHILD CURRENTLY SEE A THERAPIST? 4. HAS THE CHILD BEEN IN THE HOSPITAL RECENTLY?

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ADDITIONAL INFORMATION - Continued
5. HAS THE DEPARTMENT OF CHILDREN AND FAMILIES BEEN INVOLVED?

NO NO NO NO NO NO
ASSAULT OTHERS?

YES (when): YES (describe type and frequency): YES (specify): YES (specify how often): YES (specify how often): YES (describe and how often): YES (describe and how often): YES
FOR HOW LONG WHERE

6. IS THE CHILD INVOLVED WITH SUBSTANCE ABUSE? 7. HAS THE CHILD VIOLATED CURFEW (Out past 11 p.m.) ? 8. DOES THE CHILD ENGAGE IN VERBAL ARGUMENTS IN THE HOME BEYOND SIMPLE TALKING BACK (i.e, screaming or swearing)? 9. DOES THE CHILD ENGAGE IN PHYSICAL VIOLENCE IN THE HOME?

DAMAGE PROPERTY?

NO NO
WHEN (Dates) REASON(S)

10. HAS THE CHILD HAD PREVIOUS OUT-OF-HOME PLACEMENTS, INCLUDING WITH OTHER FAMILY MEMBERS?

COMMENTS Use this space to provide comments/explanations that will assist the processing of this complaint by the court.

COMPLAINANT'S SIGNATURE

RELATIONSHIP OR AGENCY AND TITLE (if applicable)

DATE SIGNED

NOTICE: The child may not be placed in detention based on this complaint.
JD-JM-120 (back/page 2) Rev. 10-07

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