Fill and Sign the Social History Format

Rev. 01/2001JUV-21 SOCIAL HISTORY FORMAT IN THE JUVENILE COURT OF ______________________________ COUNTY, GEORGIA Child's Name: ______________________________ DOB _________________ Court Officer: ______________________________ I. OFFENSE DATA : A.Prior Offenses Discuss previous contacts with the Juvenile Court in this coun ty as well as any contacts with courts in other counties. B. Current Offense List the current complaint which brings the child befor e the Court and discuss any relative information which would shed light on the c ircumstances surrounding the offense. II. FAMILY DATA : Describe the family constellation in which the child is living. Which family members are regularly in the household? A. Father - Absent or present in the home? Is there a st epfather? Explain and define roles. Describe either or both along the following di mensions: (a) role in the home- relationship with spouse, type and consistency of disci pline (b) employment - type of job, income, hours worked (c) r ole in community. Are there any outstanding problems: medical, emotional, dr ug/alcohol? B. Mother/Stepmother or Other Female Care-taker - Defin e roles. Describe either or both along the same dimensions as father above. C. Other Significant Adults - Age, sex, relationship to c hild. D. Siblings - Are any of the siblings positive resources f or the child? Have any been involved with court? E. Home Life - Describe housing, neighborhood. Have there been any traumatic experiences (deaths, illness, divorces, etc.)? Descri be basic feelings of family members toward each other (caring, hostile, indiffer ent). Has the family been referred to or involved in, counseling? F. Discuss how the child perceives the present situation a nd how the court involvement has impacted upon the lives of the family members. Is the child remorseful and willing to face whatever the court dec ides or is the child hostile and difficult to work with? Will the family resist effor ts by the court to help or are they willing to cooperate with the worker? If there has be en any prior Court involvement, what was the child and family's reacti on to it? Rev. 01/2001JUV-21 III. CHILD'S PERSONAL HISTORY AND ADJUSTMENT : A. Physical Health 1. Medical History - Give a general physical description . Discuss in detail any serious illness or handicaps. 2. Drug/Alcohol Involvement - Is the use/abuse of drugs or alcohol involved in the child's offense(s)? B. School - Academic and Vocational Aptitude - Discuss sc hool attendance, achievement, behavior and extra curricular activities. Has the child any career goals, work experience or vocational interests? C. Leisure Time - Has the child any special interest, ta lents, or activities? D. Treatment Efforts - Has the child been referred to or evaluated by psychologists, mental health clinics, etc.? Has the child been prev iously placed in a Youth Development Center or other DJJ residential program o r non-residential program? What other agencies are now or have been involved wi th child? IV. RECOMMENDATIONS : These should be well thought-out and reasoned recommend ations which include justification for each recommendation. It should cont ain goals and the recommendations should be the means to achieve those ends. If the rec ommendation is for probation you should state what your goals are for the child and re late how you intend to help the child reach those goals. If you recommend restitution you sh ould specify how much, to whom it should be paid, how it should be paid and how the victim should receive it. (Should the child be required to deliver it in person or pay it int o the clerk of the Court?) Rev. 01/2001JUV-21 SOCIAL HISTORY FACE SHEET Worker _______________________________________ County ______________________________________ Name ______________________________ Case # _______________________ Date___________ Address _____________________________________________________________________________ Social Security # _______________ Race / Sex ________ DOB ________ Phone # _________________ School __________________________________ Phone # ___________________ Grade ____________ FatherMotherOther Male Other Female Full Name Address: If different from child Marital Status Occupation Income Highest Grade Siblings' Name(s) AgeSiblings' Address( es)Marital Status Occupation Highest Grade Has a psychological or psychiatric evaluation been done ?Date: / / By Whom: ___________________________________ Other agencies involved with family: ______________________________________________________ Current Offense:_______________________________________________________________________ History of Prior Dispositions Informally adjusted or adjudicated offenses Comp. DateDisposition Date DisposedDate Discharged