Court Name

Address

City, State, Zip

REPORT FOR THE	Click here to enter text.
PROBATE COURT FOR TEMPORARY CUSTODIAN

Date: Click here to enter text.

Child for Whom the Petition was Filed:

Name: Click here to enter text.

Date of Birth: Click here to enter text.

Address: Click here to enter text.

Parents:

Mother: Click here to enter text.

Date of Birth: Click here to enter text.

Address: Click here to enter text.

Father: Click here to enter text.

Date of Birth: Click here to enter text.

Address: Click here to enter text.

Proposed Temporary Custodian:

Name:	Click here to enter text., (Relation): Click here to enter text.

Date of Birth: Click here to enter text.

Address: Click here to enter text.

Procedural History

(Include information regarding:

parents: a brief description of each parent and any substance abuse, domestic violence or mental health concerns; whether or not they are consenting to the petition; their current living arrangements;

when, where, and by whom, petition was filed at Probate Court;

petitioner: brief description of petitioner including any substance abuse, domestic violence or mental health concerns; whether petitioner previously had guardianship of the child(ren), if so, when; living arrangements and employment history;

child: a brief description of the child, including any specialized needs or concerns; if currently residing with the petitioner, how long and a brief history of the placement.

Include dates of visits or conversations. Also document, if applicable, use of SDM or protective factors worksheet, as well as recommendations for use of Community Provider Agencies.)

Click here to enter text.

Click here to enter text.

Click here to enter text.

Click here to enter text.

DCF History:

On (date), DCF LINK and CMS checks were completed on parents, proposed custodians and other adult household members with the following results.

Click here to enter text.

Criminal History:

On (date), Criminal police checks were completed on parents, proposed custodians and other adult household members with the following results:

Click here to enter text.

Sex Offender Registry:

On (date) , Sex Offender Registry checks were completed on parents, proposed custodians and other adult household members with the following results:

Click here to enter text..

Judicial Website:

On (date), judicial criminal, civil and housing website checks were completed for parents, proposed custodians and other adult household members with the following results.

Click here to enter text.

Department of Motor Vehicles Search:

On (date), Department of Motor Vehicle checks were completed for parents, proposed custodians and other adult household members with the following results.

Click here to enter text.

Recommendation:

The Department of Children and Families recommends (does not recommend) temporary custody be given to (the petitioner). (List brief basis, i.e. parents are not capable of providing care; child is doing well with proposed custodian; note issues that may be outstanding: counseling, services, etc.)

Click here to enter text.

Submitted by:_____________________

DCF Social Worker

Reviewed by:______________________

DCF Social Work Supervisor

Approved by:______________________

DCF Program Manager