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June 2010

52. Yes

Has the child ever had a pre-adoptive placement? No

Has the child ever experienced an adoption dissolution? 53. Yes I f y e s , w h y No ? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ______________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

54.

List the permanency resources (i.e. adoption by grandmother, adoption by foster parent) that have already

been explored & excluded:

Permanency Solution

Reason for exclusion/failure to place

________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

55.

How many caseworkers have handled this case up to the date of this review?

____________

Siblings

56.

Are siblings mentioned in court orders resulting from the Probable Cause, Adjudicatory or Dispositional

Hearing?

Yes

No

Date of Birth

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

____ / ____ /

____

_____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F _____________________________ M F

Gender

Any

57

.

Name

Siblings:

Also in

Currently

DFCS Care? Placed with? Disability?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes No

Yes No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

58.

Is this child in a sibling group that

may be placed

together?

Yes

No

If yes, circle the siblings above that can be placed with this child

59. Yes

Is this child’s membership in a sibling group delaying permanency for this child? No

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