Caretakers Information Form

CAREGIVER COURT INFORMATION FORM

Child: Caregiver:
D.O.B: Length of stay in caregiver’s home
Hearing Date: years and months

As the child’s caregiver you have the right to be present and heard at hearings and are encouraged to attend. You may appear and
provide information verbally and/or submit written information to the court. This form will be submitted to the juvenile officer to file
with the court. All parties to the case will have access to the information you provide and you may be called to testify. You are
encouraged to provide written factual information which is relevant to the child. Please type or print clearly in ink and submit the
form three weeks in advance of the hearing, or within time frames established by local protocol to the child’s case manager. See 42
U.S.C. 675(5)(G), 211.171 RSMo, 211.464 RSMo, 210.566 RSMo, and Rule 124.02

Current picture of child if
available

1. List child’s strengths/talents:

2. In what extracurricular activities/special interests is the youth involved? (i.e. athletic, fine
arts, other)

3. Is there health information about the child you would like to share?

4. Is there information about the child’s current medications you would like to share?

5. Is there behavioral information you would like to share?

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 6. Is there educational information you would like to share? (i.e. include any information about
tutoring/special services or IEP and educational achievements)

7. Are there Older Youth issues (for children 14 and older) you want to share? (i.e. child is in
need of the following life skills:)

8. List any services the child needs which they are not receiving:

9. Do you have comments regarding family interactions? (i.e. visits, phone calls, schedules)

10. Is there anything else you wish to bring to the attention of the court?

Type or print name Signature Date

Please feel free to use the back if enough space was not provided.

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 Form Completion Instructions

This form should be completed by the caregiver for each foster youth in the caregiver’s home at every
court hearing and returned to the youth’s juvenile officer three (3) weeks in advance of the hearing, or
within time frames established by local protocol.

Identifying Information
• Enter the name of the foster youth and date of birth
• Enter the name of the caregiver completing the form and the amount of years/months the foster
youth has been in the home
• Enter the hearing date
• Include a current picture of the foster youth

Questions 1 and 2
Questions 1 and 2 provide an opportunity for the caregiver who has the daily contact with and parenting
responsibility of the foster youth to present the foster youth.
Question 1 provides an opportunity to brag on the achievements and the personal attributes of the foster
youth.
Question 2 provides the opportunity to provide a clear picture of the events the foster youth is involved
in and interested in which provide social, community and cultural development.

Questions 3-9
Questions 3-9 are designed to provide an opportunity for you to share pertinent information that relates
to the safety, well-being and permanency of the foster youth placed in your home. Not all the questions
may need to be completed for each court hearing. Answer only those questions that are relevant to the
foster youth’s case.

Question 3
Include information about the health of the foster youth that is important to understanding the progress,
concerns, and/or needed services to meet the foster youth’s health needs.
Example:
James completed stress tests resulting in diagnosis of asthma and is now participating in therapy and
medications to manage his asthma effectively.

Question 4
Enter information regarding the foster youth’s medication that as the youth’s caregiver you believe is
necessary for the reader to understand any medication concerns or needs.
Example:
Sally was taking 6 medications 9 months ago and with the assistance of the pediatrician and therapist
she is now taking only 2 medications and maintaining very well her moods swings and anger outbursts.

Question 5
Enter information regarding the foster youth’s behavior that is important for the reader to understand the
progress, or lack thereof, for safety, well-being and permanency.
Example:

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Molly struggled with peer relationships creating many conflicts at school, church and in the
neighborhood. Some of the conflicts at school resulted in in-school suspensions. Molly is working
diligently with me on positive responses to stressful situations using the Step Charts and has had no
school suspensions since the last court hearing. She has made two new friends who attend the church
youth group and together they are supporting and encouraging each other to demonstrate positive and
acceptable social behaviors.

Question 6
Enter information regarding the foster youth’s achievements and/or challenges in the area of education
to provide a clear understanding of the status the foster youth is experiencing with education including
identification of success of educational services, or need of educational services.
Example:
George is struggling with respecting personal space. A new goal has been added to his IEP to address
this.

Question 7
For foster youth that are 14 years of age and older, share issues that are enhancing or hindering their
development of life skills to achieve independence.
Example:
Sam was hired at McDonalds to work three days a week after school. He has not missed a scheduled
day and his manager has reported that he is diligent and works well with the team.

Question 8
The list of services which would meet specific needs for the foster youth’s safety, well-being and
permanence that the foster youth is currently not receiving.
Example:
Tom needs a therapist that specializes in play therapy. There are none within in a reasonable distance.

Question 9
Provide information to answer question 9 if there are issues effecting the safety, well-being or
permanency of the foster youth directly related to the interactions the foster youth has with his/her
family.
Example:
I have been supervising the visits between Sharon and her paternal grandparents. I observe that this
couple could be a possible permanency option if Sharon’s mother is convicted and sentenced to
incarceration.

Question 10
This question provides the opportunity for you to bring any issue that the court needs to be aware of
regarding the foster youth’s safety, well-being, and permanency that was not covered by the previous
questions.

• Print or type your name
• Sign and enter the date you are submitting the form to the foster youth’s juvenile officer

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