In Re: (children's names, in order of age)

Probate Court, District of: (town and address)

PROBATE COURT STUDY FOR [TEMPORARY CUSTODY, REMOVAL OF GUARDIAN, REINSTATEMENT OF GUARDIAN OR TERMINATION OF PARENTAL RIGHTS]

Date:

1. Child for Whom Petition is Filed/Children for Whom Petitions are Filed

Name(s) and current address(es) or placement address(es)

Date(s) of Birth

Indian tribe affiliation(s), if applicable

Note: Dates of birth need to be verified through birth certificates. Please put "verified" next to any date of birth that has been verified by a birth certificate.

2.	Parents

Name(s)

Address(es)

Military status, if applicable

3. Siblings Not Named in Petition

Name(s)

Date(s) of birth

Address(es)

4.	Proposed Guardian(s)/Caregiver(s)Temporary Custodian(s)

Name(s)

Date(s) of birth

Address(es)

5. Parents' History

A. Mother

B. Father [use separate section for each father]

[Parents' family history should include the following information:

1	Birth name, date of birth, place of birth, citizenship, birth order, relevant information regarding parents’ parents and siblings

2. Nationality or ethnic background or Indian tribe

3. Education

4. Early social history

5. Employment history

6. Marital history (include any instances of domestic violence)

Health history, both physical and psychological (include any

hospitalizations, chronic illnesses or substance abuse problems)

Military service

9. Police record/CPS record (include unsubstantiated reports)

10. Members of the household, relationship(s) to child, date(s) of birth,

police record(s), CPS record(s)]

6. Child for Whom Petition is Filed/Children for Whom Petitions are Filed

A. [Discuss each child individually:

1. Date of birth

2. Developmental history

3. Medical history

4. School history

5. Placement history

6. Interests and attitudes

7. Results of physical and psychological exams

8. Relationship with parents, siblings and proposed

guardian/custodian/caregiver

9. Other significant persons in the child’s life]

B. Siblings [for whom petitions have not been filed]

[Note any information relevant to the allegations before the court.]

7.	Proposed Guardian/Custodian/Caregiver

[[Discuss each person individually:

1. Birth name, date of birth, place of birth, degree of relatedness to the child, relevant information regarding their parents and siblings.

2. Nationality or ethnic background or Indian tribe

3. Education

4. Early social history

5. Employment history

6. Marital history (includie any incidents of domestic violence)

Health history, both physical and psychological (include any

hospitalizations, chronic illnesses or substance abuse problems)

Military service

9. Police record/CPS record (include unsubstantiated reports)

10.	Children (include any relevant information regarding the proposed

guardian/custodian/caregiver's caretaking ability

11.	Members of the household, relationship to child, date of birth, police

record, CPS record

12.	Relationship with the child

13.	Plan to provide care for the child, e.g. support network, day care

14.	Relationship with the child's parents]

8. Family Resources

[A brief paragraph identifying family resources and strengths, such as relatives, friends and other supports the family may utilize. Describe the nature of the relationships and describe the resources and networks supporting the family. Identify who are the important people in the child(ren)’s life; describe their interest and interaction with the child(ren). If any family resources are responsible for the care for the child, please add CPS and police history for those persons.]

9.	Other Agencies

[Name and describe services that the parents, proposed guardians/custodians/caregivers and/or children were offered by public or private agencies; services available in the community, with or without DCF involvement; and degree of compliance with services by family members.]

10.	Present Situation

[Describe the current situation of the parents and proposed guardian/custodian/caregiver and child(ren), including interpersonal relationships, child's interaction and relationship with parents, proposed guardian/custodian/caregivers and any other members of the household; details of the child’s placement; and how he/she is adapting.]

9. Summary and Recommendations

Summary

[Briefly summarize:

Whether the investigation found support for the allegations.

Whether the investigation identified new allegations.

Whether the parents are appropriate caretakers.

Whether the proposed temporary custodian/guardian/caregiver is an appropriate placement.

The recommendation(s) of the Department regarding the disposition of the pending petition.

Any other recommendations regarding visitation or support services the family and/ or child(ren) may need.]

Submitted by: (Social Worker)

Reviewed by: (Social Work Supervisor)

Approved by: (Program Supervisor)