Our vision is that every child involved in the child welfare or juvenile justice systems becomes resilient, safe, healthy, and economically secure.

Care Giver Questionnaire - Probation

This survey is for anyone who is providing the 24/7 care of the child/youth, regardless of the placement type.

What is reported in this questionnaire may be included in the local board's report to the legal parties to the case.

Your First Name: Required

Your Last Name: Required

Your Email Address:

If responding for more than one youth, use the oldest youth's first name and last initial.

First Name of Youth: Required

Last Name: (1st Initial Only) Required

City: Required

State: Required

Board #: If Known

Meeting Date: If Known

System Contact

Do you receive adequate communication and updates from the Probation Officer regarding the needs of this youth?

Explain

Have you received enough background information regarding the youth to meet his/her needs adequately? (medical/educational/behavioral/mental health, or any other special needs)

Explain

Medical Information

List the youth's current prescription medications:

Provide dates of the youth's last Physical, Dental, and Eye Exam:

List any of the youth's mental health needs:

Any unmet medical and/or mental health needs?:

Describe any positive/negative behaviors of the youth, and what is being done to address them.

Explain

Services

Describe services(treatments) being provided to the youth, and youth compliance and progress with each service.

Explain

If there are unmet needs or concerns, please explain:

Does the youth have developmental disabilities?

Yes No

Has the youth qualified for development disability specific services?

Describe services if they are being provided.

Explain

Describe any unmet needs or concerns.

Explain

If over the age of 18, is there a plan for DD services and supports after the age of 19?

Yes No

Explain

Education

Describe how the youth is doing in school. (grades, behaviors, successes) Explain

Describe what extracurricular activities the youth enjoys and is involved in. Explain

Is there anything keeping the youth from being involved in these activities? Explain

Does the youth have a current IEP and if so, is it being followed? Explain

Does the youth need an IEP, or need an updated IEP?

Yes No

What is being done to complete this?

Explain

Additional Information

Is there anything else that you would like us to know? Explain

Although not required, if you would like to submit any additional related documents you may do so below:

Total file size for all files cannot exceed 17MB.

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By the return of this document online, you attest that the information is true and accurate.

Please call the System Oversight Specialist on this case at the phone number listed in the letter you received. Otherwise call our main office at 402-471-4420 for assistance.

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"The soul is healed by being with children." Fyodor Dostoevsky

"There is no trust more sacred than the one the world holds with children." Kofi A. Annan

"Seek the wisdom of the ages, but look at the world through the eyes of a child." Ron Wild

"Children have more need of models than of critics." Carolyn Coats

Care Giver Questionnaire - Probation

System Contact

Explain

Explain

Medical Information

Explain

Services

Explain

Education

What is being done to complete this?

Additional Information

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