Attachment #2.pdf

Page 1 of 8 Form C-2.3B 02-2018

Parent Interview

NAME and JJMS #: DATE:

COUNTY: JUDGE:

PO: DETAINING: YES NO

DRUG SCREEN: YES NO PSYCHIATRIC: YES NO

Outcome:

Current Charge and Date of Incident:

What is your account of the offense and charge(s)? What’s your understanding of what happened?

Background Information:

For any applicable parents/caregivers, indicate the following: (1) legal guardian / custody?, (2) age, (3) ever married, (4) number of children & ages, (5) educational background, (6) job information, (7) legal history, (8) quality of relationship with juvenile, (9) were they interviewed?

**If youth is adopted, but info is available for both birth & adoptive parents, include both

Mother’s Name & Info:

Father’s Name & Info:

Step-Parent’s Name & Info:

Step-Parent’s Name & Info:

Form C-2.3B

Other (Grandparents; Adoptive or Birth Parents) Names & Info:

Family Functioning

Who currently lives in the home? (Names, ages, relationship to juvenile)

How long has your child lived with you? Ever lived with other relatives? Out-of-home placements?

DSS removal?

What is your current relationship with your child?

How is your child’s relationships with his/her siblings?

What are your child’s responsibilities or chores at home?

Does your child have a curfew? Ever broken curfew? Run away? Sneak out at night?

What is your child’s behavior like at home? When did they start having behavior problems at home?

Does your child ever get physically or verbally aggressive with anyone in the household?

Who disciplines your child? What punishments or rewards are used? Do they work?

If employed, what hours do you work? Who watches your child/children while you are at work?

Are you getting financial help from any agencies (e.g. WIC, food stamps, disability check, Medicaid) What and for how long?

Ever been involved with DSS? When and why? Outcome?

Is there a family history of domestic violence? (Give examples – hit, pushed, shoved, had something thrown at you, threatened you verbally or with a weapon, was controlling). If yes, explain:

How is your health? Do you take any medications? If so, what are the medications for? (Also ask for other parents and live-in or long-time partners)

Are you aware of any family history of mental health issues? If so, who? What is the diagnosis?

Any family history of self-harm, suicide attempts, or completed suicide? (Ask of all parents and live-in or long-time partners)

Have you ever been involved with the police or arrested for any reason? If so, why? Has anyone else in your family been involved with the legal system? If so, who and why? (Ask of all parents and live-in or long-time partners)

Is there any family history of alcohol or drug use? If so, who? Substance of choice? Received treatment? (Ask of all parents and live-in or long-time partners)

Have there been any significant family events that could have impacted your child, such as divorce, deaths, homelessness, or frequent moves?

What are some activities that you and your child do together as a family?

Developmental History

Did you/child’s mother experience any problems or complications during pregnancy and/or delivery? Were there any unusual or stressful events that occurred during the pregnancy? How old were you (she)? Did you (she) receive prenatal care? Were you (she) prescribed any medications during the pregnancy?

Did you/child’s mother use drugs, alcohol, or tobacco during the pregnancy? If so, what was used and how often were they used?

Were there any problems or delays with regard to your child(‘s):

Learning to crawl:

Learning to walk:

Hearing:

Intellectual development:

Potty-training:

Speech/language development:

Social development:

Movement or coordination:

How would you describe your child’s health now? Does your child take any medication? Ever taken medication? If so, why, name of medication, dosage and frequency? Has your child ever had major illnesses, hospitalizations, broken bones, head injuries, concussions, seizures, allergies, asthma?

As far as you know, has your child ever used alcohol, marijuana, tobacco, or other drugs (over the counter medications)? If so, what substances? Age started? Frequency?

As far as you know, does your child have a history of physical, sexual or emotional abuse, or neglect? If so, what happened? By whom? What was done? What is the status of the case/charges?

Is your child currently involved with any community agencies or programs (e.g., Big Brother/Big Sister, church programs, YWCA, JROTC)? Have they ever been involved with these programs?

Mental Health Symptoms/History If yes to any of the below, indicate when the problem began, how frequently it occurs

Has your child ever seemed sad for long periods of time?

Have you ever thought your child might be depressed? (Sadness, anger, or apathy)

Does your child often seem irritable or does he/she seem to get angry easily?

Does your child have temper tantrums?

Has your child ever tried to harm him/herself on purpose? Ever talk about suicide?

Does your child seem to worry a lot?

Is your child afraid of anything that most other kids aren’t afraid of?

Has your child ever had a panic attack (a sudden feeling of fear or anxiety, might feel like you can’t breathe, heart beating fast, sweating, shaking, chest pain, nausea, dizziness, feeling hot or cold, numbness or tingling, feeling like things don’t seem real)?

Does your child seem to have too much or too little energy?

Does your child have difficulty sitting still? Does he/she talk a lot?

Does your child have problems paying attention?

Does your child seem forgetful?

Is your child impulsive or does your child often act without thinking?

Does your child have problems with sleep (can’t fall or stay asleep?)

Does your child have problems with appetite (too much, too little)?

Has your child ever stolen anything?

Has your child ever set fires?

Has he/she ever hurt, teased, or killed an animal?

Has your child ever destroyed others’ property on purpose?

Does your child try to manipulate others to get what he/she wants?

Does your child get into fights frequently? To your knowledge, has your child ever used a weapon in a fight?

Has your child ever received counseling? If so, where, when, and why? If no longer in counseling, reason for ending? Any mental health diagnoses? Psychotropic medications? Do you feel counseling was helpful? Likes/Dislikes?

Has your child ever been hospitalized for emotional or behavioral reasons? If yes, indicate where, when, and how long child was hospitalized.

School/Job Functioning What was the last school your child attended? Grade level? Does your child receive special services at school or have an IEP? Have they in the past? What are your child’s grades (over the years & more recently)?

What is your child’s behavior like at school? Has your child ever been suspended from school? If so, why and for how long? Has your child ever been put up for expulsion from school? If so, what was the outcome?

When did the behavioral problems start? Why?

Has your child ever been sent to an alternative school? How did he/she adjust?

Does your child have any goals for the future? What would your child like to do when she/he grows up?

Peer Relations Does your child have friends? How many? Are they the same age as your child, older, younger?

Gender?

Do you think any of them are a bad influence?

Do you know your child’s friends’ parents?

What do your child and her/his friends like to do? Do they hang out at your home? If not, where do they go?

Do your child’s friends attend school?

As far as you know, do your child’s friends have a history of legal involvement or behavioral problems at school?

As far as you know, has your child ever been involved in a gang? Does your child have friends that are in a gang?

Does your child ever bully other children? Has your child been bullied?

About how much time does your child spend on social networking sites online such as Facebook, Twitter, and Instagram? Is your child’s online activity monitored? How does your child access these sites and the internet (tablet, computer, phone, etc.)?

Does your child have a current boyfriend or girlfriend? Is your child sexually active? Does your child know about safe sex? Does your child use birth control? If so, what method?

Has your child ever conceived a child? If so, what is the status (e.g., miscarried, aborted, adopted, lives with family)? Has your child ever been treated for any type of STD?

Living Arrangements/Community Functioning

What type of home do you live in? How many rooms? Does your child have his/her own room?

Do you own or rent your home?

How long have you lived at your current residence? How often have you moved?

What’s your neighborhood like (i.e., city, country, quiet, loud, safe, unsafe, gangs, drugs, police activity, prostitution)? How far away from businesses or stores are you? Walking distance?

How well does your child behave in the community? Have you ever received complaints from neighbors or parents of friends about your child?

Are you a licensed driver? Do you have reliable transportation? Does your child or anyone else in the household drive?

What do you feel are your child’s greatest strengths?

What do you feel are things that your child needs to work on?

What do you feel are your family’s greatest strengths?

What do you feel your family needs to work on?

Would you like your child to return home? Do you feel that she/he needs an alternative placement?

Do you have any questions for me or concerns you would like to discuss?