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Name_________________________________________
Home Phone_______________
Address_______________________________________
Work Phone________________
City_________________________________State_________Zip___________
Type of case:
___Physical Abuse ___Sexual Abuse ___Neglect
Other:____________
County:__________________________
Name of Case
Worker:_____________________
Date case opened:_____________
Children removed
from home: ___Yes ___No
Number of children:________
Ages: _____________
Where are they:
_______________
If children
were in foster care, how
long_______________________________________
Were your parental
rights terminated?___________________
If children
were examined medically or psychologically:
Where: ___________________
By whom:____________________________________________
Name of attorney:
________________________________
Phone:__________________
Case opened because:
___Hotline report
___Divorce/CustodY
___Mandated
reporter (Doctor, hospital, teacher, etc.
___Other________________________________________
Name/Title of
reporter (if known)
____________________________________________
Brief description
of case:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Attach copy of
DFS Form CS-21 if you have it available (State Form
describing investigation
process)
Was there a court
order? ____________________
Were you notified
of hearings?____________________________
Date case was
resolved (if ever)______________________
What was resolution?_____________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________
Would you like the opportunity to tell your story in a public forum? _________________
Vocal may keep this information: ______________________
Vocal may publish
this information or pass on to legislature.___________
_________________________________________________
(Your signature)
(In the case
of E-Mail, typed signature will stand in the place of actual signature.)