Policy Manual
COURTS
Superior Court For Juvenile Matters

Attachment to 46-3-25

In Re: (child's name)

Date of Birth:  (month, day, year)

Superior Court for Juvenile Matters at:  (address)

STUDY FOR CHILD FOR WHOM DCF IS THE STATUTORY PARENT 

Name: (name of child)                                                                                                                        

 Address (number, street, city/town) and with whom (relationship): 

Date of Placement: (month, day, year)

 Type of Placement: (Pre-Adoptive, Foster Care, Relative) 

Court of Original Jurisdiction: (address)

 Date of Termination: (month, day, year)

 I.          Circumstances of Termination: (cause of termination)

                        Briefly describe circumstances of termination: (brief explanation of cause)

 II.          Current Situation:

                        What is child's current placement situation?

                        What alternatives have been attempted (adoption, custody care by other person, long term foster care)

           III.          Child's Placement History Since Termination:

                        List placement(s) with date(s) and adjustment issues.        IV.          Child's Adjustment:

                        1.         In current placement or living situation.

                        2.         School (name, location, grade, special education)

                        3.         Special needs/services being provided including  health considerations.

           V.          DCF Plan for Child:

Include time frame, measurable objectives, and time schedule for moving child into permanency.  Also document reasonable efforts to achieve permanency.

Submitted by: (Social Worker's signature and date)

Reviewed by: (Social Work Supervisor's signature and date)

Approved by: (Program Supervisor's signature and date)