Policy Manual
COURTS
Superior Court For Juvenile Matters

Attachment to 46-3-14

In Re:  (name of child) 

Superior Court for Juvenile Matters:  (address) 

Date: 

SUMMARY OF FACTS SUBSTANTIATING ALLEGATIONS OF NEGLECT 

Child for Whom Petition is Filed/Children for Whom Petitions are Filed: 

• Name  (full name)

• Address  (street number and name, city, state, zip code) (or DCF licensed foster   home)

• Date of Birth  (month, day, year)

• Indian Tribe (if applicable) 

(NOTE: YOU MUST NAME A TRIBE IF THERE IS A  CLAIM OF ANY NATIVE AMERICAN HERITAGE OF ANY KIND. THE CHILD DOES NOT HAVE TO BE A REGISTERED MEMBER OF A TRIBE) 

Mother: (Include all mothers in same case ) 

• Name  (legal full name)

• Address [or last known address]  (street number and name, city, state, zip code)

• Prison Identification Number (if applicable)

• Date of Birth (month, day, year)

• Indian Tribe (if applicable) 

Father: (Include all fathers in same case) 

• Name  (legal full name)

• Address [or last known address]  (street number and name, city, state, zip code)

• Prison Identification Number (if applicable)

• Legal Status (putative or acknowledged)

• Date of Birth

• Indian Tribe (if applicable) 

Reasons for Petition: 

[This section should state in numbered, double-spaced, brief, paragraph form the allegations that, if true, would establish that the child is neglected, uncared for or dependent.  This section should not include all the evidence, witnesses, and testimony that would be used at trial to prove the allegations. For example:] 

1.   Since 1990, there have been five substantiated reports concerning the family involving incidents of domestic violence between the parents and substance abuse by Mr. ________. 

2.   Recently, on (date), the child has been exposed to and witnessed repeated domestic violence in the home.  

3.   Recently, on ____________, during this incident of domestic violence, the child was injured when father threw a chair at mother, accidentally hitting the child. 

4.   Mr. ___________ was intoxicated at the time of the domestic violence incident. 

5.   The child has asthma that the parents are not properly treating.  

6.   The child is behind on her immunizations and cannot attend school.

Reasonable and Active Efforts to Prevent Removal:  

[In this section, list all services available to the parents. It is not necessary to detail their degree of compliance. If no services have been offered, state the reason.] 

Referrals have been made to the Women’s Center domestic violence counseling program,  Alcoholics Anonymous, United Services’ anger management program, the Hospital Pediatric Clinic.  

Submitted by:  (Social Worker) 

Reviewed by:  (Social Work Supervisor) 

Approved by:  (Program Supervisor)