Form Pkt-008 - Domestic Violence - Restraining Order With Children Packet Page 15
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23CONFIDENTIAL
CASE NAME
CASE NUMBER
MEDICAL AND DENTAL INFORMATION
Child(ren) Doctor's Name
Tel. No.
ADDRESS
Number and Street
Apt. #
City
State
Zip Code
List medical/dental information to be discussed at FCS
EDUCATION
Child
Name of School
Teacher/Counselor
Grade
1.
2.
3.
4.
COUNSELING
Is
Child(ren)
Father
Mother in Counseling?
Yes
No
Counselor for
Counselor for
Counselor's Name
Counselor's Name
Address
Address
Tel. No.
Tel. No.
When did counseling begin?
When did counseling begin?
CHILD(REN)’S ACTIVITIES AND OTHER SPECIAL NEEDS
(Such as special classes, team activities, and transportation to and from these activities)
1. Are there allegations of verbal intimidation or threats?
Yes
No
2. Has there been physical violence between the parents?
Yes
No
If yes, how long ago?
0 – 6 mos.
6 mos. – 1 yr.
1 yr. or more
. Has law enforcement been involved?
Yes
No
3
Provide details
:
4. Have there been allegations of abuse against the child(ren)?
Yes
No
a. If yes, when:
b. Who made the allegations?
c. Who was the alleged abuser?
d. Has Child Welfare Services (CWS) been involved?
Yes
No
e. CWS worker's name and telephone number
FAMILY COURT SERVICES (FCS) DATA SHEET
SDSC FCS-002 (Rev. 5/16)
Page 2 of 3
(CONFIDENTIAL)
Mandatory Form
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