Request for Modification/Termination of Designated Felon Order Request For: Modification Termination Date, if any, of last request: Youth’s Name: DOB: JTS ID#: Region: District: County: Youth Parent/Guardian Facility/Community Case Manager Name: Name: Address 1: Address 1: Address 1: Address 2: Address 2: Address 2: City, State, Zip: City, Zip: City, State, Zip: Phone: Phone: Phone: PDRA Level and Safety Plan Current Safety/Supervision Plan: Y N N/A (attach if PDRA Risk Level: Low Medium High applicable) Higher Sights Level: White Blue Green Gold OFFENSE HISTORY Committing Judge: DF Commitment Order Date: Committing Offense: # Months Restrictive Custody Ordered: Pending Charges: County Date Charge A/J (juvenile & adult, including traffic) SIX MONTH REPORTS (attach all reports) Date of Reports: , , , , , , , , , , SERVICE PLAN / TREATMENT PROGRESS Goal Area / Intervention Progress Comments Offense/Conditions % % Basic Care Criminogenic % Impact of Crime Class Restitution Amount Ordered: Amount Paid: Community Service Hours Ordered: Hours Done: Supervision Fees / Fines Amount Ordered: Amount Paid: Summary of any treatment interventions (ex: substance abuse, failed drug screens, sex offender, etc.) and progress made: ACADEMIC AND/OR VOCATIONAL PROGRESS (attach current transcript) School Attendance: Grade Level: Classroom Behavior Reports: Extracurricular Activities: GED or H.S. Diploma Received: Y N Employed: Y N If so, ATTACHMENTS JTS Graduated Sanctions Summary: Safety/Supervision Plan and Relapse Victim Impact Statement: Disciplinary Hearing Reports: Prevention Plan, if applicable: Youth personal statement: Placement History Report:
Request for Modification/Termination of Designated Felon Order Request For: Modification Termination Date, if any, of last request: Youth’s Name: DOB: JTS ID#: Region: District: County: Youth Address 1: Address 2: City, State, Zip: Phone: Parent/Guardian Name: Address 1: Address 2: City, Zip: Phone: Facility/Community Case Manager Name: Address 1: Address 2: City, State, Zip: Phone: PDRA Level and Safety Plan PDRA Risk Level: Low Medium High Current Safety/Supervision Plan: Y N N/A (attach if applicable) Higher Sights Level: White Blue Green Gold OFFENSE HISTORY Committing Judge: DF Commitment Order Date: Committing Offense: # Months Restrictive Custody Ordered: Pending Charges: (juvenile & adult, including traffic) County Date Charge A/J SIX MONTH REPORTS (attach all reports) Date of Reports: , , , , , , , , , , SERVICE PLAN / TREATMENT PROGRESS Goal Area / Intervention Progress Comments Offense/Conditions % Basic Care % Criminogenic % Impact of Crime Class Restitution Amount Ordered: Amount Paid: Community Service Hours Ordered: Hours Done: Supervision Fees / Fines Amount Ordered: Amount Paid: Summary of any treatment interventions (ex: substance abuse, failed drug screens, sex offender, etc.) and progress made: ACADEMIC AND/OR VOCATIONAL PROGRESS (attach current transcript) School Attendance: Grade Level: Classroom Behavior Reports: Extracurricular Activities: GED or H.S. Diploma Received: Y N Employed: Y N If so, ATTACHMENTS JTS Graduated Sanctions Summary: Disciplinary Hearing Reports: Placement History Report: Safety/Supervision Plan and Relapse Prevention Plan, if applicable: Victim Impact Statement: Youth personal statement:
DJJ20.35AttachmentB.docx