Does the child/young adult currently receive services from the Agency for Persons with Disabilities Yes No (APD)? Pending If yes, list the type of APD services: DEPENDENTS Yes No Does the child/young adult have any children? If yes, provide: Name(s): DOB(s): Gender(s): Does the child/young adult have custody of the child(ren)? Yes No If no, list the individual(s) with custody and the to the child/young adult: individual’s relationship/role Does the child/young child receive any type of services? Yes No adult’s List the name(s) and type of services received: Does the child/young adult require any assistance with obtaining services for his/her child(ren)? Yes No If yes, include in the follow-up activities. Yes No Does the child/young adult require child support for his/her child(ren)? N/A If yes, discuss efforts being taken to assist the child/young adult with filing for child support: LEGAL INFORMATION DJJ Involvement Has the child/young adult EVER had any DJJ or Adult Criminal Justice involvement? Yes No Does the child/young adult have any current charges? Yes No If yes, list the charge(s) and status for each: Does the child/young adult have a probation officer (Juvenile Probation Officer - JPO/ Probation Officer Yes No – PO)? If yes, provide the Location: Name of JPO/PO: Phone Number: List any upcoming hearings (court dates and type):
Does the child/young adult currently receive services from the Agency for Persons with Disabilities (APD)? Yes No Pending If yes, list the type of APD services: DEPENDENTS Does the child/young adult have any children? Yes No If yes, provide: Name(s): DOB(s): Gender(s): Does the child/young adult have custody of the child(ren)? Yes No If no, list the individual(s) with custody and the individual’s relationship/role to the child/young adult: Does the child/young adult’s child receive any type of services? Yes No List the name(s) and type of services received: Does the child/young adult require any assistance with obtaining services for his/her child(ren)? If yes, include in the follow-up activities. Yes No Does the child/young adult require child support for his/her child(ren)? Yes No N/A If yes, discuss efforts being taken to assist the child/young adult with filing for child support: LEGAL INFORMATION DJJ Involvement Has the child/young adult EVER had any DJJ or Adult Criminal Justice involvement? Yes No Does the child/young adult have any current charges? Yes No If yes, list the charge(s) and status for each: Does the child/young adult have a probation officer (Juvenile Probation Officer - JPO/ Probation Officer – PO)? Yes No If yes, provide the Location: Name of JPO/PO: Phone Number: List any upcoming hearings (court dates and type):
5405_CSEC%20Services%20Plan.docx