Your name
Address
Mobile Phone
Your email
Date of First Contact with CFS
County Your Case is in
What Office is Working Your Case
Who is Your Social Worker (Name & Phone Number)
Who is Your Social Worker’s Supervisor (Name & Phone Number)
What is Your Case Number (It Should Start with The Letter J)
Who is Your Lawyer (Name & Phone Number)
Who is Your Support System
Are You a Member of a church —Please choose an option—YesNo
Do You Currently Attend School —Please choose an option—YesNo
Highest Level of Education —Please choose an option—ElementaryMiddle SchoolSome High School High School GraduateGEDSome CollegeAssociates DegreeBachelors DegreeMasters DegreeDoctorate (PHD)Trade SchoolVocational Certification
What is Your Living Situation —Please choose an option—HomelessLiving with Family/FriendsLiving in a ShelterRentOwn
Do You Have Medical Insurance —Please choose an option—YesNo
What is the Stage of your Case —Please choose an option—InvestigationRemovalDetention HearingOther
If Other, What Stage is Your Case in
Have You Had any Status Reviews of Your Case —Please choose an option—YesNo
Are Your Children Currently Detained by CFS —Please choose an option—YesNo
If Yes, What Date Were They Removed
How Many Children Have Been Removed
List Names and Ages of all Siblings
What is the Recommendation by CFS —Please choose an option—Reunification ServicesNo Reunification Services
Date of your Next CFT (Children and Family Team) Meeting
Date of Your Next Appointment
What Services or Programs has CFS Recommended You Complete —Please choose an option—ParentingAnger ManagementAATherapyOther
If Other, What Service or Program was Recommended by CFS
What Services are You Looking to get From Haven’s Future —Please choose an option—ParentingAnger ManagementAATherapyLegal AidHousing ReferralsEmployment ReferralsAdvocationOther
If Other, What Services are you looking to get from Haven’s Future
Tell Us Your Story
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