Free Caregiver Information Form - Nebraska

CAREGIVER INFORMATION FORM
Child: Hearing Date: Completed by: Relationship: Legal Case Number:

To the Foster Parent or Relative Caregiver of the child: Neb. Rev. Stat. § 43-1314.02 (2007 Neb. Laws, L.B. 457, § 1) requires courts to provide a Caregiver Information Form to foster parents. You may submit written information to the court, and you can be heard at review and permanency hearings. This optional form may assist you in providing written information to the court. You are encouraged to provide information based only on first-hand knowledge. You do not have to complete every item on the form. Please type or print clearly in ink and submit the form 2 weeks in advance of the hearing to the Clerk of the Court. You also have the right to be present at the hearing, and you are encouraged to attend. All parties to the case will have access to the information you provide, and you may be required to testify about this information. 1. Child's Name: Date of Birth: 2. Name of Caregiver: Address: Type of Caregiver: Foster Parent Relative Group home/residential treatment facility Other (specify): Phone: Age:

3. The child has been living in my home for ____ years and ____ months. Current Picture of Child

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Name of Caregiver: Name of Child:

Case Number:

4. Current Status of Child's Medical/Dental/General Physical Condition: ____ I have no new or additional information since the last court hearing ____ I have new or additional information since the last court hearing (briefly describe)

5. Current Status of Child's Emotional Condition: ____ I have no new or additional information since the last court hearing ____ I have new or additional information since the last court hearing (briefly describe)

6. Current Status of Child's Education: ____ I have no new or additional information since the last court hearing ____ I have new or additional information since the last court hearing (briefly describe)

The child ___ is ___ is not a special education student. Date of the last Individual Education Plan (IEP) was:

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Name of Caregiver: Name of Child: 7. Current Status of Child's Social Skills/Peer Relationships:

Case Number:

____ I have no new or additional information since the last court hearing ____ I have new or additional information since the last court hearing (briefly describe)

8. Current Status of Child's Special Interests/Activities: ____ I have no new or additional information since the last court hearing ____ I have new or additional information since the last court hearing (briefly describe)

9. Current Status of Child's Reactions Before/During/After Visits: ____ I have no new or additional information since the last court hearing ____ I have new or additional information since the last court hearing (briefly describe)

10. ____ I have no concerns regarding visitation arrangements. ____ I have concerns regarding visitation arrangements. (please specify)

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Name of Caregiver: Name of Child: 11. Is child receiving all necessary services?: ____ Yes ____ No

Case Number:

Explain:

12. Caseworker has visited child: Month Place (face to face) By Phone

13. Caseworker has visited with Foster Parent: Month Place (face to face) By Phone

14. The Guardian Ad Litem has acquired information about child through: ____ Personal Visits dates (see below) ____ I have provided monthly caregiver reports ____ Other (specify): Guardian Ad Litem has visited child: Month Place (face to face) By Phone

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Name of Caregiver: Name of Child: 15. My child has a CASA worker: CASA worker has visited child: Month Place (face to face) ____ Yes ____ No

Case Number:

By Phone

16. Other concerns or comments about child:

17. If child is not able to be reunified with his/her biological family, and if consideration for permanency is with us, I am/We are: ____ ABLE to make a permanent commitment to child. ____ NOT ABLE to make a permanent commitment to child. ____ UNSURE if we will be able to make a permanent commitment to child.

Date:

(Type or print name)

(Signature of Caregiver)

Please feel free to use the back for more detailed information.

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