Stanislaus — Caregiver Information Form

Source: https://www.stanislaus.courts.ca.gov/system/files/forms-and-filings/jv-290-carefiver-information-form.pdf

JV-290 SUPERIOR COURT OF CALIFORNIA, COUNTY OF STANISLAUS FOR COURT USE ONLY STREET ADDRESS: 2215 Blue Gum Avenue, Room 15 MAILING ADDRESS: 2215 Blue Gum Avenue, Room 15 CITY AND ZIP CODE: Modesto, CA 95358 BRANCH NAME: Juvenile Division

CHILD'S NAME:

HEARING DATE AND TIME:

CASE NUMBER:

CAREGIVER INFORMATION FORM

To the current caregiver, preadoptive parent, community care facility, or foster family agency caring for the child: You may submit written information to the court, and you may attend review and permanency hearings. You may use this optional form to provide written information to the court. Please type or print clearly in ink and submit the original and eight copies of the form to the court clerk's office at least five calendar days (or seven calendar days, if filing by mail) before the hearing. Be aware that other individuals involved in the case have access to this information. See form JV-290-INFO for instructions on how to complete this form and file it with the court.

1. a. Child's name: b. Child's date of birth: c. Child's age:

2. Caregiver Information (Answer only if you are a caregiver, skip #3.): a. Name of caregiver: b. Type of caregiver: Foster parent Relative Legal guardian Preadoptive parent Nonrelative extended family member Other (specify): c. The child has been living in my home for (specify): years months.

3. Agency or Facility Information (Answer only if you are an agency or facility, skip #2.): a. Name of agency or facility: b. Address: c. Telephone number: d. Type of facility: Foster family agency Community care agency Other (specify): e. The child has been placed with our agency/facility for (specify): years months and in the current home for (specify): years months. f. Name of person completing form: Title: g. Hours per week the person completing this form spends with the child (specify): hours/week. h. The information on this form consists of (1) the observations and recommendations of the person filling out this form. (2) the observations and recommendations of a group or team made up of the following individuals (specify):

4. Current Status of Child's Medical, Dental, and General Physical and Emotional Health

   a. There is no new or additional information since the last court hearing.

   b. There is new or additional information since the last court hearing, as follows (do not include the names of doctors):

5. Current Status of Child's Education a. There is no new or additional information since the last court hearing. b. There is new or additional information since the last court hearing, as follows (do not include the names of schools):

Form Approved for Optional Use CAREGIVER INFORMATION FORM Welfare and Institutions Code, §§ 366.21(c), (d); Judicial Council of California Cal. Rules of Court, rule 5.534(k) JV-290 [Rev. September 1, 2020] www.courts.ca.gov

JV-290 CHILD'S NAME: CASE NUMBER:

6. Child's Special Education Status a. The child is a special education student. Date of last Individualized Education Plan (IEP): b. The child is not a special education student. c. I do not know the child's special education status.

7. Current Status of Child's Adjustment to Living Arrangement a. There is no new or additional information since the last court hearing. b. There is new or additional information since the last court hearing, as follows:

8. Current Status of Child's Social Skills and Peer Relationships a. There is no new or additional information since the last court hearing. b. There is new or additional information since the last court hearing, as follows:

9. Current Status of Child's Special Interests and Activities a. There is no new or additional information since the last court hearing. b. There is new or additional information since the last court hearing, as follows:

10. Other Helpful Information a. There is no new or additional information since the last court hearing. b. There is new or additional information since the last court hearing, as follows:

11. Recommendation for Disposition (Outcome) a. I have no recommendation for disposition (outcome). b. I am recommending the following disposition (outcome):

12. If you need more space to respond to any section on this form, please check this box and attach additional pages.

    Number of pages attached:

    NOTICE

If you are not the child, child's parent, or child's legal guardian, you may have a right to challenge a decision by the juvenile court, but only in very limited circumstances. You may need a court order granting you access to records in the juvenile case file. For more information, please see Information on Requesting Access to Records for Persons With a Limited Right to Appeal (form JV-291 - INFO). You can get form JV-291-INFO at any courthouse or county law library or online at www.courts.ca.gov/forms.

Date:

(TYPE OR PRINT NAME) (SIGNATURE OF CAREGIVER OR FACILITY/AGENCY STAFF PERSON
WHO HAS COMPLETED THIS FORM)

JV-290 [Rev. September 1, 2020] CAREGIVER INFORMATION FORM Page 2 of 2