PARENT / FAMILY INTAKE FORM

CLASS ACTION LAWSUIT

Date of Intake:_________________

Parent / Family Member Name

Calling:________________________________________________________________

ADDRESS:______________________________CITY____________STATE________ZIP___________

HOME PHONE (______)__________________ MOBILE PHONE: (______)__________________

Custodial Parent Name:____________________________________________________

1. Child(ren)

NAME(S) DOB AGE NOW AGE WHN CPS TOOK

1.______________________________ _______________ _________ ____________

2.______________________________ _______________ _________ ____________

3.______________________________ _______________ _________ ____________

4. ______________________________ _______________ _________ ____________

5. ______________________________ _______________ _________ ____________

6. ______________________________ _______________ _________ ____________

7. ______________________________ _______________ _________ ____________

2. Date CPS took them and WHY they say they took them (their allegations)

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 ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________

3. Names of CPS agents including supervisors, case workers, investigators, guardian ad litems,
psychologists; include E-mail and phone numbers.

NAME(S) Position / Title Phone E-mail

1.______________________________ __________________ __________________________

2.______________________________ __________________ __________________________

3.______________________________ __________________ __________________________

4. ______________________________ __________________ __________________________

5. ______________________________ __________________ __________________________

6. ______________________________ __________________ __________________________

7. ______________________________ __________________ __________________________

4. Name of the judge_________________________________________________________________

5. Name of the Court / City / County etc.__________________________________________________
6. Copy of the last order YES__________ NO_________
7. Copy of ALL case plans / reunification plans YES _________ NO_________

Please keep it simple.

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I need the documents in order to help you.

They have to be reviewed.

________________________________________

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WHAT WE CAN DO IS THIS :

1. Review your case, orders, notes, etc….. All documents concerning your case.
2. Contact CPS and let them know we are working WITH YOU to accomplish your "case / reunification
plan" they have ordered.
3. Supply the court with a report on your behalf indicating the true progress that you have made (vs.
CPS' report being the only one supplied to the court)
4. Assign a FAMILY CASE ADVOCATE AND FAMILY COUNSELOR to you and your child(ren) and
extended family members to be with you at certain meetings in your area (this is the hardest one to
bring to pass; but, we will work on it for you and try to get someone in your area for you).
5. File suit when they break the law. Not when your case is over or headed that way. ****

***** THERE ARE DIFFERENT CAUSES OF ACTION THAT CAN BE FILED IN DIFFERENT
CASES. SOME CASES DO HAVE THE SAME CAUSES OF ACTION. THESE MATTERS ARE UP TO
THE LEGAL PROFESSIONALS TO DECIDE AFTER REVIEWING YOUR CASE WITH YOU. PLEASE
SUPPLY YOUR INTAKE REPRESENTATIVE WITH THE REQUESTED INFORMATION SO THAT YOU
CAN BE PROPERTY ASSISTED. NO QUESTIONS WILL BE ANSWERED UNTIL THE CASES ARE
REVIEWED INDIVIDUALLY. IT WOULD NOT BE FAIR TO YOU TO DO SO.

DOCUMENTS FROM FAMILY:

_________ CASE MANAGEMENT PLAN

_________ REUNIFICATION PLAN / AGREEMENT SIGNED BY PARENT_____YES______NO
_________ TEAM REVIEW MEETING PLAN
_________ COURT ORDERS
_________ PETITIONS FILED BY CPS
_________

PARALEGALS:

___________ CREATE A CHRONOLOGICAL TIME LINE OF ALL ACTIONS i.e. PLEADINGS FILED, COURT
DATES, HEARINGS, MEETINGS, VISITATIONS, etc. (all pertinent memorable events in the case; use
documents and parent / family statements)

___________ CREATE A CASE SUMMARY OF ALL ACTIONS FOR ATTORNEY REVIEW.

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