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Fill and Sign the Wisconsin Child 497431098 Form

Fill and Sign the Wisconsin Child 497431098 Form

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State of Wisconsin, Circuit Court,       County 1. Intake Case Number       Court Referral - Child/Juvenile (Non-Law Enforcement Referral) 2. Court Case Number       3. Child's/Juvenile's Name (Last, First, Middle)       4. Alias/Nickname       5. Age      6. Date of Birth       7. Sex Male Female 8. Child's/Juvenile's Street Address City State Zip Code       9. County of Residence       10. Race     1. White 2. Black 3. Asian 4. Indian 5. Other 11. Home Telephone       12. School Attended/Place of Employment       13. Grade/Occupation       14. Legal Father's Name Address       Marital Status       T E L E P H O N E Work:       Home:       15. Legal Mother's Name Address       Marital Status       Work:       Home:       16. Guardian/Legal Custodian/Supervising Agency Address       Marital Status       Work:       Home:       17. Name of Referring Agency Address       18. Telephone Number       19. Prior Record with Referring Agency: No Yes If yes, describe manner of handling: Additional information attached. 20. Name of Referring Person             21. Reason(s) for Referral: Statute Number(s):       Describe Allegation(s): Additional information attached.       INTAKE INQUIRY RECOMMENDATION 22. Date Received       23. Interview Date and Time:       24. Present at Interview:       25. Custody Authorization: Released Detained Date:       Time:       Nonsecure:       Secure:       26. Prior Referrals to Intake: No Yes How Many?       27. Intake Recommendation - Check all appropriate boxes. A. Case Closed Dismissed - lacks jurisdiction Counseled Referred to Other County Other: (Specify)       B. Deferred Prosecution/Informal Disposition Agreement Expires:       Supervised Work Program:       hrs. Informal Supervision Other: (Specify)       C. Formal Petition Requested In Need of Protection/Services under ch. 48 In Need of Protection/Services under ch. 938 28. Comments:       JD-1702 , 05/00 Court Referral - Child/Juvenile (Non-Law Enforcement Referral) §§48.24 and 938.24, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Court Referral - Child/Juvenile (Non-Law Enforcement Referral) Page 2 of 2 Case No. 29. Name of Intake Worker/Agency       30. Signature 31. Telephone       32. Date Recommended       JD-1702 , 05/00 Court Referral - Child/Juvenile (Non-Law Enforcement Referral) §§48.24 and 938.24, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2

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