Child Description

Child’s Name PID No. CHILD DESCRIPTION Suffix Last Name First Name Middle NameRace Sex DOB Primary LanguageIDENTIFICATIONPID Number Status Social Security Number SID NumberActive InactiveAdditional ID Type ID Number StateHair Color Eye Color Height WeightCitizenship Place of BirthDistinguishing MarksADDITIONAL INFORMATION # of Lives With? Pregnant? Parent? # of Marital Status Children SiblingsReligious Preference Gang Membership Gang Affiliation Degree of InvolvementHard Core/Professional Gang Member Gang MemberFormer Gang Member Wanna' BeALERTCASEWORKER/5 October 2008 Page 1 of 22 Child’s Name PID No. ABUSE Suspected Abuse CPS CPS Contact Other Agencies Involved (circle all that apply) Involved?Sexual Physical EmotionalSubstance(s) Abused Severity RationaleMild(experimental) Moderate(regular use) Suspected ConfirmedSevere(addicted) Unknown Acknowledged Mild(experimental) Moderate(regular use) Suspected ConfirmedSevere(addicted) Unknown AcknowledgedADDRESSESAddress 1 Phone Type Phone Number Ext.Address 2 Phone Type Phone Number Ext.City State Zip Code Phone Type Phone Number Ext.ALIASAliasDRUG TESTSTest Date Result Administered By Funding SourcePositive Results (circle all that apply)Alcohol Amphetamines Benzodiapines Cocaine Marijuana Methamphetamines Opiates PCDCommentsCASEWORKER/5 October 2008 Page 2 of 22 Child’s Name PID No. EMPLOYMENTEmployer Name Hire Date Termination DateAddress 1 Pay Period SalaryAddress 2 City State Zip Code PhoneEMPLOYMENTEmployer Name Hire Date Termination DateAddress 1 Pay Period SalaryAddress 2 City State Zip Code PhoneFINANCIALIncome Source Income Period AmountEffective Date Effective End DateFINANCIALIncome Source Income Period AmountEffective Date Effective End DateFINANCIALIncome Source Income Period AmountEffective Date Effective End Date CASEWORKER/5 October 2008 Page 3 of 22 Child’s Name PID No. MEDICALHealth Insurance Carrier Health Insurance Policy NumberMedicaid TANF TANF Number IV-E Eligible CHIP ReceivingEligible Receiving Eligible ReceivingMedical InformationBEHAVIORAL HEALTH MH/MRMental Health Needs Treatment Prior to Juvenile Involvement Date Determined Mentally IllNo Prior Hospitalization Prior Treatment UnknownIQ Test Scores Test Used Verbal Nonverbal FullBEHAVIORAL HEALTH REFERRALSReferral Date Presenting Problem Referred ForMental Health Substance AbuseReferred To Outcome CostFunding Source Type of Assessment/EvaluationCASEWORKER/5 October 2008 Page 4 of 22 Child’s Name PID No. BEHAVIORAL HEALTH TESTINGTest Date Primary Diagnosis Secondary DiagnosisAxis I Primary Secondary Diagnosis 3 Diagnosis 4 Diagnosis 5Axis IIAxis IIIAxis IV Axis V GAFECON EDUC HOUS OCCU OTHR LEGL SOCL HLTH SUPPBEHAVIORAL HEALTH TREATMENTTreatment Begin Date Treatment End Date Presenting ProblemMental Health Substance AbuseService Referred To CostSCHOOLSSchool Status Entrance Date Exit Date School DistrictIS HS GR GD CSDO SE AE JJ PSSchool Last Grade Current Failing? Years Special Education? Completed Grade BehindHandicapping ConditionEmotionally Disturbed Mentally Retarded OtherLearning Disabled Physical DisabilityCASEWORKER/5 October 2008 Page 5 of 22 Child’s Name PID No. ASSOCIATESLast Name First Name Middle Name SuffixPrimary Language Race Sex DOB Age Address Same as Child?Address 1 Phone Type Phone Number ExtensionAddress 2 Phone Type Phone Number ExtensionCity State Zip Code Phone Type Phone Number ExtensionSocial Security Number ID Type ID Number ID StateEmployer Marital StatusPrior Involvement Prior Substance Substances Abused Mental Illness (circle all that apply) Abuse?Juvenile Adult Gang Yes No UnknownRelationship to Child Legal Guardian Cleared for VisitationCASEWORKER/5 October 2008 Page 6 of 22 Child’s Name PID No. ASSOCIATESLast Name First Name Middle Name SuffixPrimary Language Race Sex DOB Age Address Same as Child?Address 1 Phone Type Phone Number ExtensionAddress 2 Phone Type Phone Number ExtensionCity State Zip Code Phone Type Phone Number ExtensionSocial Security Number ID Type ID Number ID StateEmployer Marital StatusPrior Involvement Prior Substance Substances Abused Mental Illness (circle all that apply) Abuse?Juvenile Adult Gang Yes No UnknownRelationship to Child Legal Guardian Cleared for VisitationCASEWORKER/5 October 2008 Page 7 of 22 Child’s Name PID No. REFERRAL INTAKEReferral Number Referral Date CountyReferral TypeFormal Paper Complaint Paper Formalized Interim/Permanent Transfer Crisis Intervention Non-Jurisdiction Municipal/Justice of the Peace ParoleContract Detention Other Administrative Interstate Compact Contract Placement Referral Source Age Intake OfficerPolice Agency Probation DepartmentOther School Texas Youth CommissionAddress Location School Status Alternative Ed Prgm In Regular School Dropped Out GED County Resident Out of CountyHome School Charter School Out of State Out of U.S.A. Private School Graduated JJAEP Suspended or ExpelledEducational Standing Last Grade In Need of Substance Abuse Services Completed Yes, not being treated Yes, being treated Passing/Appropriate Grade Failing/Behind Grade No Suspected UnknownStd Assessment Date Risk Assessment Level Further Testing Recommended By?Assessment EvaluatorOFFENSEComplaint Received Offense Date Arrest Date Referring Agency DateIncident Number DPS TRN Number DPS TRS NumberPreparatory Counts Offense CodeWeapon If firearm, Gang Sub Abuse Type of Substance Abused School School Campus Type What type? Related? Related? RelatedIntake Indicator Disposition IndicatorCASEWORKER/5 October 2008 Page 8 of 22 Child’s Name PID No. Primary Secondary Added @ Disp Revised @ Disp Primary Consolidated DismissedOFFENSEComplaint Received Offense Date Arrest Date Referring Agency DateIncident Number DPS TRN Number DPS TRS NumberPreparatory Counts Offense CodeWeapon If firearm, Gang Sub Abuse Type of Substance Abused School School Campus Type What type? Related? Related? RelatedIntake Indicator Disposition IndicatorPrimary Secondary Added @ Disp Revised @ Disp Primary Consolidated DismissedOFFENSEComplaint Received Offense Date Arrest Date Referring Agency DateIncident Number DPS TRN Number DPS TRS NumberPreparatory Counts Offense CodeWeapon If firearm, Gang Sub Abuse Type of Substance Abused School School Campus Type What type? Related? Related? RelatedCASEWORKER/5 October 2008 Page 9 of 22 Child’s Name PID No. Intake Indicator Disposition IndicatorPrimary Secondary Added @ Disp Revised @ Disp Primary Consolidated DismissedCASEWORKER/5 October 2008 Page 10 of 22 Child’s Name PID No. OFFENSEComplaint Received Offense Date Arrest Date Referring Agency DateIncident Number DPS TRN Number DPS TRS NumberPreparatory Counts Offense CodeWeapon If firearm, Gang Sub Abuse Type of Substance Abused School School Campus Type What type? Related? Related? RelatedIntake Indicator Disposition IndicatorPrimary Secondary Added @ Disp Revised @ Disp Primary Consolidated DismissedOFFENSEComplaint Received Offense Date Arrest Date Referring Agency DateIncident Number DPS TRN Number DPS TRS NumberPreparatory Counts Offense CodeWeapon If firearm, Gang Sub Abuse Type of Substance Abused School School Campus Type What type? Related? Related? RelatedIntake Indicator Disposition IndicatorCASEWORKER/5 October 2008 Page 11 of 22 Child’s Name PID No. Primary Secondary Added @ Disp Revised @ Disp Primary Consolidated DismissedCASEWORKER/5 October 2008 Page 12 of 22 Child’s Name PID No. MAYSIScreening Date Administered Reason Not Administered Yes NoMAYSI ScoresAD AI DA SC SI TD TEReferred for Further Assessment Referred to Where Received Further AssessmentYES NO Yes No UnknownVICTIMLast Name First Name Middle Name SuffixPrimary Language Race Sex DOB AgeAddress 1 Phone Type Phone Number ExtensionAddress 2 Phone Type Phone Number ExtensionCity State Zip Code Phone Type Phone Number ExtensionIndividual Relationship to Offender Crime against Crime Against Victim Person? Person? Property? Deceased?Restitution Waive Unpaid Balance? Victim Notification DateAttached to Offense (date and offense): CASEWORKER/5 October 2008 Page 13 of 22 Child’s Name PID No. VICTIMLast Name First Name Middle Name SuffixPrimary Language Race Sex DOB AgeAddress 1 Phone Type Phone Number ExtensionAddress 2 Phone Type Phone Number ExtensionCity State Zip Code Phone Type Phone Number ExtensionIndividual Relationship to Offender Crime against Crime Against Victim Person? Person? Property? Deceased?Restitution Waive Unpaid Balance? Victim Notification DateAttached to Offense (date and offense): CASEWORKER/5 October 2008 Page 14 of 22 Child’s Name PID No. DETENTIONType of Detention Reason Facility Date Detained Time DetainedSecure Non-Secure Offense/Behavior No Alt Place OtherDate Released Time Released Cost per Day Total Cost Released toAttached to Referral (date and primary offense): DETENTIONType of Detention Reason Facility Date Detained Time DetainedSecure Non-Secure Offense/Behavior No Alt Place OtherDate Released Time Released Cost per Day Total Cost Released toAttached to Referral (date and primary offense): DETENTIONType of Detention Reason Facility Date Detained Time DetainedSecure Non-Secure Offense/Behavior No Alt Place OtherDate Released Time Released Cost per Day Total Cost Released toAttached to Referral (date and primary offense): DETENTIONType of Detention Reason Facility Date Detained Time DetainedSecure Non-Secure Offense/Behavior No Alt Place OtherDate Released Time Released Cost per Day Total Cost Released toAttached to Referral (date and primary offense): CASEWORKER/5 October 2008 Page 15 of 22 Child’s Name PID No. DISPOSITION Petition Date Cause No. AttorneyRecommended Disposition Primary DispositionDisposition Date Controlling Diverted To Where? Disp?SJS Date LS Score ES Score SI Score CC Score Determinate SentenceMonths YearsCourt Presiding JudgeGuideline Level Assigned Level Previously Assigned LevelDeviation Exists? Supervision Ordered DEFP PROB ISP Level 5 PlacementPrimary Deviation Reason Secondary Deviation Reason Additional Deviation ReasonComment for Other Deviation ReasonFEES ASSESSEDVictim Date Ordered Type Amount (month) Total First Payment Due DateCASEWORKER/5 October 2008 Page 16 of 22 Child’s Name PID No. COMMUNITY SERVICE RESTITUTIONAssessed Date Hours AssessedDescriptionAttached to Referral (date and primary offense): SUPERVISIONBegin Date Estimated End Date Actual End DateSupervision Type Officer Level/PhaseConditionsOutcomeCase Plan Review Date Next Review Date Officer Review Type Imminent Risk of Removal?Initial Exit ReviewedCase PlanAttached to Referral (date and primary offense):CASEWORKER/5 October 2008 Page 17 of 22 Child’s Name PID No. PROGRAMProgram Referral Date Begin Date Estimated End Date Actual End DateProgram Provider Officer Level/Phase Funding SourceConditionsOutcomeAttached to Referral (date and primary offense):PROGRAMProgram Referral Date Begin Date Estimated End Date Actual End DateProgram Provider Officer Level/Phase Funding SourceConditionsOutcomeAttached to Referral (date and primary offense):CASEWORKER/5 October 2008 Page 18 of 22 Child’s Name PID No. PROGRAMProgram Referral Date Begin Date Estimated End Date Actual End DateProgram Provider Officer Level/Phase Funding SourceConditionsOutcomeAttached to Referral (date and primary offense):CASEWORKER/5 October 2008 Page 19 of 22 Child’s Name PID No. RESIDENTIAL PLACEMENT Placement Type FacilityCPS Placement Emergency Shelter Foster Care Kinship Placement (by court) Parental Placement Residential (non-secure) Secure CorrectionalService TypeBootcamp Correctional Female Offender Mental Health Other Pregnant Female Sex Offender Substance Abuse Treatment Placement Date Cost Per Day Level of Care Funding SourceDays per Week IV-E Certified Estimated Release Date Actual Release DateDischarge Reason Child Progressing? Total CostCase Plan Review Date Next Review Date Officer Review TypeInitial Exit ReviewedCase PlanAttached to Referral (date and primary offense):NON-RESIDENTIAL SERVICESService In Date Cost Provider ServiceFunding SourceAttached to Referral (date and primary offense): CASEWORKER/5 October 2008 Page 20 of 22 Child’s Name PID No. CASEWORKER/5 October 2008 Page 21 of 22 Child’s Name PID No. JUVENILE JUSTICE ALTERNATIVE EDUCATION PROGRAM (JJAEP)Entrance Date Expulsion Date PIEMS Student ID Campus ID School District Expulsion Offense CodeOffense Description Court Status Grade Tested GL Tested GL Spc Education?/Type Level Math ReadingAdult Juv /Std Math Score Std Reading Score Exit DateJuvenile Court Disposition Tested GL Math Tested GL ReadingPROB ADLT NOTG DEFP DISM PEND REFU SUPVC Std Math Score Std Reading Expulsion Supervision Ended? Days Attended Days Absent Score Ended?Yes No Yes NoExit ReasonEXPX PROBX RTRS GRAD OTHR GED UNSCCASEWORKER/5 October 2008 Page 22 of 22

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