Step 1 of 2 50% Name(Required) Phone(Required)Email(Required) Please enter all the adults in your family. First Name Last Name Relationship to children Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Please enter all the children in your family. Name Current age of child Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Who was accused? Parents Name What type of abuse was alleged against this parent? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Were any of your children removed from your home?YesNoList of children Child name Date this child was removed from the home? Was child placed in Kinship or Foster Care? Who was Foster Care Agency? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Do Any of your children have medical diagnoses or conditions that existed prior to accusation?YesNoList of children Child name Select Medical Conditions that apply for any of your children Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Were any of your children in the hospital or ER when this first allegation occurred?YesNoList of children Child Name Which hospital/s or ER/s? Please List any doctor’s names involved in this hospital encounter Did a parent ever meet with the Child Protection Team doctors? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Did any of the children’s initial accusation come from the pediatrician’s office?YesNoNot SureList of children Child name Select which network the pediatrician is associated with: Other Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Following the accusation, were any of your children admitted into the hospital?YesNoList of children Child name Where was this child admitted? How long were they admitted to the hospital? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Did any of your children attend any visit/appointment at the CAC center (Child Advocacy Center at 17th & Chew)?YesNoList of children Child name Who recommended the child go there? Were any tests/procedures run on this child while at the CAC? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Were you assigned a CYS case worker?YesNoWhat was the name of the Caseworker/s? What county was the Caseworker from? Was any parent ever interviewed by police?YesNoList of parent Parent name Which police department and where? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Did any parent take a polygraph test?YesNoList of parent Parent name Select one Who paid for the polygraph? Did this parent have an attorney? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Did any of your children have a Guardian Ad Litem?YesNoList of children Child name Type in name of GAL Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Did either parent sign a Family Service Plan?YesNoWhich child/children was the signed plan for? : select any that apply First Choice Second Choice Third Choice Did any parent/s or children receive any of the following services during the period of accusation? Select any that apply Psychological Evaluation Parenting Classes Domestic Violence classes Anger Management classes Protective Parenting classes In Home Services (i.e Family Reunification, Justice Works, KidsPeace, Homestead, K&S, Pinebrook) Individual Counseling, Couples Counseling or Family Counseling Other Other Psychological Evaluation Parent/Child name Select one Name of practice or psychologist who completed the evaluations? What was result of the evaluation (i.e. diagnosis? Recommendations made?) Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Parenting Classes Parent name Select one Name of agency/company who provided the evaluations? Who paid for the classes? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Domestic Violence classes Parent name Select one Name of practice or agency who provided the classes? Who paid for the classes? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Anger Management classes Parent Name Select one Name of practice or company who provided the classes? Who paid for the classes? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Protective Parenting classes Parent name Select one Name of practice or company who provided the classes? Who paid for the classes? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. In Home Services (i.e Family Reunification, Justice Works, KidsPeace, Homestead, K&S, Pinebrook) Parent/Child name Select one Name of practice or agency who completed the evaluations? Who paid for the services? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Individual Counseling, Couples Counseling or Family Counseling Parent/Child name Select one Name of practice or agency who provided the counseling? Who paid for the counseling? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Other Parent/Child name Select one Name of practice or agency who provided the counseling? Who paid for the counseling? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Damages: Please select all that apply to you or your family due to the accusations and aftermath: Job Loss Loss of Income Reputation damage Loss of license/ or change to job status/position Money loss/court related expenses Divorce/ Pressured separation Inappropriate questions Invasion of Privacy Fear of seeking any help such as medical care or counseling Emotional Distress/PTSD/Mental Health repercussions What documents do you have to support your case?Dependency related Emergency Petition Dependency Petition Transcripts from court proceedings Court Docket Discovery documents Other Court Document Criminal related Police documents Polygraph results Warrant Jail/Bond Paperwork Bodycam/ Survaillance Camera Criminal trial Court documents Transcripts Child Line related CY47 CY48 ChildLine notification letters/ DHS letters BHA appeal documents BHA Appeal Decision Non Pursuit Letters Medical Records related to accusations Portal Messages/My Chart messages Did you see CAC (Child Advocacy Records)? Do you have images? (Portal Messages/My Chart messages) Do you have images? (Child Advocacy Records) Medical Records prior to accusations Portal Messages/ MyChart messages Do you have images? Emails Cys GAL Hospital Doctors Foster Care Financial Documents Medical Billing records Insurance Explanation of benefits Receipts Loss income Receipts Psych evals Classes Polygraph Counseling