CASA Report Form to the Court

2. Case Identifier/Number*

   Insert Case JC#

3. Case Status*

   1. Alleged
   2. Adjudicated
   3. N/A

5. CASA/GAL Name*

   Use your CASA/GAL name

6. Choose one*

   1. CASA/GAL
   2. Attorney: Pro Bono

7. Add a 2nd CASA/GAL

   1. Yes
   2. No

9. CASA/GAL #2

10. Choose one

    1. CASA/GAL
    2. Attorney: Pro Bono

12. Child Name*

    First Name, Last Name

13. Date of Birth*
    Date of Birth

14. Add a 2nd child

    1. Yes
    2. No

16. Child Name 2

17. Child 2 Date of Birth
    Child 2 Date of Birth

18. Add a 3rd child

    1. Yes
    2. No

20. Child Name 3

21. Child 3 Date of Birth
    Child 3 Date of Birth

22. Add a 4th Child

    1. Yes
    2. No

24. Child Name 4

25. Child 4 Date of Birth
    Child 4 Date of Birth

26. Add a 5th Child

    1. Yes
    2. No

28. Child Nname 5

29. Child 5 Date of Birth
    Child 5 Date of Birth

30. Add a 6th Child

    1. Yes
    2. No

32. Child Name 6

33. Child 6 Date of Birth
    Child 6 Date of Birth

35. Basis for Court Involvement:

37. Check all that apply*

    1. Dependancy
    2. Neglect
    3. Physical Abuse
    4. Sexual Abuse
    5. Emotional Abuse
    6. Crossover
    7. Custody/Visitation
    8. Other

38. Other Description

40. Type of Hearing
    -- Select One --Adjudication/DispositionAnnual ReviewCustodyDelinquencyDispositionMediationParental RightsPermanent CustodyPPLAVisitionOther

41. Other Description

43. Date of Complaint/Petition
    Date of Complaint/Petition

44. Date of GAL Appointment
    Date of GAL Appointment

46. Assigned to Judge
    -- Select One --CASA Office should insert JudgeDenise Navarre CubbonConnie ZemmelmanVisiting Judge:

47. Visiting Judge Name

49. Assigned to Magistrate
    -- Select One --AdyaCairlHutchesonJonesFieldRestivoRutledgeSorahOther:

50. Other Magistrate name

52. Prior CASA/GAL Report(s) Filed

    1. No
    2. Yes, See Court File

54. CASA/GAL has Attended all Hearings since Appointment

    1. Yes
    2. No

55. Photo

57. Date of Missed Hearing
    Date of Missed Hearing

58. Reason for Missed Hearing
    -- Select One --Another GAL CoveredEmergencyIllNo Notice of HearingOther

59. Other Reason for Missed Hearing

60. Add Missed Hearing Date #2

    1. Yes
    2. No

62. Date of Missed Hearing #2
    Date of Missed Hearing #2

63. Reason for Missed Hearing #2
    -- Select One --Another GAL CoveredEmergencyIllNo Notice of HearingOther

64. Other Reason for Missed Hearing #2

65. Add Missed Hearing Date #3

    1. Yes
    2. No

67. Date of Missed Hearing #3
    Date of Missed Hearing #3

68. Reason for Missed Hearing #3
    -- Select One --Another GAL CoveredEmergencyIllNo Notice of HearingOther

69. Other Reason for Missed Hearing #3

70. Add Missed Hearing Date #4

    1. Yes
    2. No

72. Date of Missed Hearing #4
    Date of Missed Hearing #4

73. Reason for Missed Hearing #4
    -- Select One --Another GAL CoveredEmergencyIllNo Notice of HearingOther

74. Other Reason for Missed Hearing #4

75. Add Missed Hearing Date #5

    1. Yes
    2. No

77. Date of Missed Hearing #5
    Date of Missed Hearing #5

78. Reason for Missed Hearing #5
    -- Select One --Another GAL CoveredEmergencyIllNo Notice of HearingOther

79. Other Reason for Missed Hearing #5

80. Add Missed Hearing Date #6

    1. Yes
    2. No

82. Date of Missed Hearing #6
    Date of Missed Hearing #6

83. Reason for Missed Hearing #6
    -- Select One --Another GAL CoveredEmergencyIllNo Notice of HearingOther

84. Other Reason for Missed Hearing #6

86. Case History

    Include the information in the numbered paragraphs of the LCCCS Complaint beginning with paragraph 4 and then add "At the Emergency Shelter Care Hearing held on (insert date) the Court awarded _______ custody and the children were placed ________."

88. Documents Reviewed

90. Agency
    -- Select One --A OK ProgramCentralized Drug TestingChild Advocacy Center (CAC)CRC (Visits)Cullen CenterEast Toledo Family CenterHarborHelp Me GrowLucas County SheriffLCCSLucas County Juvenile CourtRescue CrisisSASISt. Charles HospitalSt. Vincent HospitalToledo HospitalUnisonOther

91. Type of Document
    -- Select One --Drug TestFileMedical RecordsPolice CheckReportOther

92. Re: Who?
    -- Select One --ChildChildrenFamilyFatherFather's GirlfriendMaternal AuntMaternal GrandfatherMaternal GrandmotherMaternal Great GrandfatherMaternal Great GrandmotherMaternal UncleMotherMother's BoyfriendParentsPaternal AuntPaternal GrandfatherPaternal GrandmotherPaternal Great GrandfatherPaternal Great GrandmotherPaternal UncleStep FatherStep MotherOther

93. Add Document #2

    1. Yes
    2. No

95. Agency Other

96. Document Other

97. Who Other

99. Agency #2
    -- Select One --A OK ProgramCentralized Drug TestingChild Advocacy Center (CAC)CRC (Visits)Cullen CenterEast Toledo Family CenterHarborHelp Me GrowLucas County SherriffLCCSLucas County Juvenile CourtRescue CrisisSASISt. Charles HospitalSt. Vincent HospitalToledo HospitalToledo PoliceUnisonOther

100. Type of Document #2
     -- Select One --Drug TestFileMedical RecordsPolice CheckReportOther

101. Re: Who? #2
     -- Select One --ChildChildrenFamilyFather's GirlfriendMaternal AuntMaternal GrandfatherMaternal GrandmotherMaternal Great GrandfatherMaternal Great GrandmotherMaternal UncleMotherMother's BoyfriendParentsPaternal AuntPaternal GrandfatherPaternal GrandmotherPaternal Great GrandfatherPaternal Great GrandmotherPaternal UncleStep FatherStep MotherOther

102. Add Document #3

     1. Yes
     2. No

104. Agency Other #2

105. Document Other #2

106. Who Other #2

108. Agency #3
     -- Select One --A OK ProgramCentralized Drug TestingChild Advocacy Center (CAC)CRC (Visits)Cullen CenterEast Toledo Family CenterHarborHelp Me GrowLucas County SheriffLCCSLucas County Juvenile CourtRescue CrisisSASISt. Charles HospitalSt. Vincent HospitalToledo HospitalUnisonOther

109. Type of Document #3
     -- Select One --Drug TestFileMedical RecordsPolice CheckReportOther

110. Re: Who? #3
     -- Select One --ChildChildrenFamilyFatherFather's GirlfriendMaternal AuntMaternal GrandfatherMaternal GrandmotherMaternal Great GrandfatherMaternal Great GrandmotherMaternal UncleMotherMother's BoyfriendParentsPaternal AuntPaternal GrandfatherPaternal GrandmotherPaternal Great GrandfatherPaternal Great GrandmotherPaternal UncleStep FatherStep MotherOther

111. Add Document #4

     1. Yes
     2. No

113. Agency Other #3

114. Document Other #3

115. Who Other #3

117. Agency #4
     -- Select One --A OK ProgramCentralized Drug TestingChild Advocacy Center (CAC)CRC (Visits)Cullen CenterEast Toledo Family CenterHarborHelp Me GrowLucas County SheriffLCCSLucas County Juvenile CourtRescue CrisisSASISt. Charles HospitalSt. Vincent HospitalToledo HospitalUnisonOther

118. Type of Document #4
     -- Select One --Drug TestFileMedical RecordsPolice CheckReportOther

119. Re: Who? #4
     -- Select One --ChildChildrenFamilyFatherFather's GirlfriendMaternal AuntMaternal GrandfatherMaternal GrandmotherMaternal Great GrandfatherMaternal Great GrandmotherMaternal UncleMotherMother's BoyfriendParentsPaternal AuntPaternal GrandfatherPaternal GrandmotherPaternal Great GrandfatherPaternal Great GrandmotherPaternal UncleStep FatherStep MotherOther

120. Add Document #5

     1. Yes
     2. No

122. Agency Other #4

123. Document Other #4

124. Who Other #4

Leave This Blank:


126. 1. Receive an email copy of this form.
127. Email address

     This field is not part of the form submission.

128. Submit

* indicates a required field