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

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