Fill and Sign the Youth Court Questionnaire under 19 Form

Page 1 of 6 Youth Court Questionnaire JC 14:11.13 Rev. 06/2019Youth Court Questionnaire (Under 19) Youth Court Information General Information First Nam e Last Name Age Today’s Dat e Court Location (City and/or County) Judge’s Name (if known) List the name(s) of anyone who helped you fill out this form and their connection to you: Is there something you would prefer to share with someone in private? Yes Current Situation 1.Are you okay with your current home? No Yes No If no, why not ? This questionnaire was designed as a way for you to inform the judge handling your case of your specific situation. The information you provide is strictly voluntary. The more details you share, the better the judge is able to make the best decision in your case. However, you do not have to answer every question. To make sure this questionnaire gets to the proper judge 1. Give it to your Guardian A d Litem (GAL), Court Appointed Special Advocate (CASA) volunteer, Caseworker, Foster Parent, Foster Care Specialist, or your personal attorney , 2. Bring it to your next hearing, or 3. Mail it to the Clerk of the Court in your city or county. Under current law, the judge, your mother and/or father, Guardian Ad Litem, caseworker and the county attorney are allowed to view your answers. The judge handling your case may ask questions regarding the information you provide. If you have questi ons or need assistance in completing the questionnaire, please contact the Nebraska Court Improvement Project via email at nsc.cip@nebraska.gov . Page 2 of 6 Youth Court Questionnaire JC 14:11.13 Rev. 06/2019 2. Where would you want to live and why? 3. Do you feel safe where you are living? If no, who or what makes you feel unsafe? 4. If you have siblings (full, half, step or adoptive), are they living with you now? (Skip, if no siblings) 5. Are your basic needs being met (getting enough to eat, having enough clothing, etc.)?If no, explain 6. Do you currently have any dental or physical health conditions? 7. If you have any dental or physical health conditions, are you receiving appropriate treatment? 8.Please use the spac e below if there is anything you want the court to know regarding your dental or physical health conditions. You may also request to speak with someone in private. 9.Describe any cur rent mental health conditions (depression, anxiety, attention problems, thoughts of hurting yourself, problems sleeping or eating, etc.). You may also request to speak with someone in private. 10. Are you in counseling/therapy? If you are attending therapy, is it helpful? If no, w hy not? Yes No Yes No If you’re not living together, where and how often do you see your siblings? Yes No Yes No Yes No If no, why not? Yes No Yes No Page 3 of 6 Youth Court Questionnaire JC 14:11.13 Rev. 06/201911. Do you take medicine? If yes, do you know what it’s for? If y es, what? 12. Are you currently attending school? If no, why not? How are things going at school ? 13. Are you participating in activities at school or el sewhere (sports, band, art club, etc.)? If no, why not? Is there something getting in the way? If yes, what are you doing and how is it going? 14. Are you currently working? If no, would you like to be? Why or why not? If yes, where are you working, how often and how is it going? Case Information 15.Which of these people/groups have you seen or talked to in the last month: Sibling(s) CASA V olunteer GAL Caseworker Therapist or Counselor Teacher(s) Mom Dad Foster Parents 16. Is there someone you’re not talking to who you want to be? If yes, explain Yes No Yes No Yes No Yes No Yes No Yes No A Team Meeting is a gathering of the Department of Health and Human Services (DHHS) or the foster care agency, your family and you to discuss services that will be provided. 17. Do you attend your team meetings? If no, why not? Yes No Sometimes Page 4 of 6 Youth Court Questionnaire JC 14:11.13 Rev. 06/2019 18. Do you feel comfortable speaking at team meetings?If no, what makes you uncomfortable? 19.Do you feel that your concerns are being addressed? Yes No Sometimes If no, explain There was a law passed in Nebraska in 2016 called the Nebraska Strengthening Families Act , which allows for youth to have two advisors of their choice on their family team. The advisor would be like a positive role model that’s a support to you because of a relationship you’ve built with that person, such as a teacher, coach, close family friend, etc. This advisor could help advocate for your participation in normal activities like peers w ho aren’t involved in the system. 20.Do you have a Strengthening Families Act Advisor ? If yes, who is serving as an advisor to you on your team? If no, who would be someone you consider as an advisor? A Case Plan is a document that DHHS or foster care agency makes and updates regularly. It includes the services provided to you and your family, and says what needs to happen to reach the goals. 21. Have you received a copy of your most recent case plan? Sometimes If yes, who gave you the copy? If not, when is the last time you got a copy of the case plan? 22. Do you understand the case plan? 23. Do you have questions about your case plan? If y es, what questions? Yes No Yes No Yes No Yes No Yes No Page 5 of 6 Youth Court Questionnaire JC 14:11.13 R ev. 0 6/2019 If you do have a CASA, do you receive a copy of their report? Sometimes A GAL Report is a document written by the Guardian ad Litem, who is an attorney representing you and your best interests, to update the court on your case. 25. Do you receive a copy of the GAL report? Sometimes When was the last time you got a GAL report? 26. Do you understand the GAL report? Sometimes In a Court Hearing, the judge makes the major decisions about you by looking at the progress of you and your parent(s) to make sure you are safe and have what you need. 27. Hav e you been to a court hearing before? If not, why not? 28. Do you know when c ourt hearings are happening? 29. Is there someone who explains what will be happening at your court hearing? Sometimes 30. Do y ou want to attend more court hearings? A Court Order is a written order from the judge after the court hearing. 31.Do you receive copies of your Court Orders? Sometimes Do you want a copy of your Court Orders? 32. Would you like the opportunity to speak to the judge in court? What would you like to talk about? 33. Is there anyone you want attending your next court hearing? If yes, who? 34. Are you uncomfortable with certain people attending your hearing? If yes, who and why? A CASA Report is a document that a Court Appointed Special Advocate (CASA) volunteer completes in order to give a summary and recommendations regarding your best interest. Not every young person has a CASA volunteer, but you can request that a judge appoint a CASA for you. 24. Do you have a CASA assigned to you? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Page 6 of 6 Youth Court Questionnaire JC 14:11.13 Rev. 0 6/2019Personal Concerns/Goals 38. What is your biggest concern with how things are going? 39.What are your plans for your future? 40.How can the judge or other people in your case help you with your goals? 41.What else would you like the court to know? An Independent Living Plan is a written plan to prepare for living on your own once you have left foster care. The plan may include goals for completing education, finding a job, finding affordable housing, managing your money, etc. If you are over 14, you should have a plan. Do you have an Independent Living Transition Plan? I don’t know 35. Have you been part of creating the plan? 36. Do you feel like you are being prepared to become an adult? 37. What c ould you use help with? Yes No Yes No Yes No