Fresno — PJV-45 Application for Family Dependency Treatment Court (FDTC)

Source: https://www.fresno.courts.ca.gov/_pdfs/forms/PJV-45 Family Dependency Treatment Court Application for Family Dependency Treatment Court (FDTC).pdf

SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO Application for Family Dependency Treatment Court (FDTC) Date: Parent’s Full Name Date of Birth Gender Ethnicity

Male Caucasian African American

Female Hispanic Asian Other:

Phone Number: Email Address:

**Only list children with open dependency case Case Number Child’s Full Name Date of Birth Gender Male Female Male Female Male Female Male Female

Case Plan: FM FR Services for Visitation

Drug Testing: No Yes Self-Help Meetings: A.A. No Yes N.A. No Yes Frequency: x wk Other: No Yes Frequency: x wk Therapy: No Yes DV Allegations: No Yes

Parent’s Attorney: Phone: Have you had an ASI Assessment? Yes NO, but I have an appointment on:

Drug(s) of Choice: Alcohol Methamphetamine Prescription Drugs Amphetamine PCP Cocaine Heroin Marijuana Other (Please Specify):

History of Any Prior Treatment? No Yes If Yes, when (List Dates and Duration):

Are you currently pregnant? Yes No N/A Do you have health insurance? Yes No

What is your current living situation? House, Apartment, Mobile Home Residential Hotel, Rooming House Homeless Residential Treatment Facility Emergency Housing/Shelter Jail/Prison Transitional Housing Other (Please Specify): Decline Is this housing safe and stable? Yes No Why?

What is your highest education level achieved? No formal schooling High School Diploma Bachelor’s Degree Less than 9th grade Some college or technical school Graduate Degree Some high school Associates or technical degree Declined

Are you currently employed? Yes No

FOR COURT USE ONLY: Applicant is: Accepted Not Accepted APPLICATION REVIEW SET IN DEPT. at 3:00 PM, on (date)

PJV-45 R07-17 F.D.T.C. Application for Family Dependency Treatment Court