COMPLAINT, NON-SCHOOL FAMILY WITH SERVICE NEEDS JD-JM-120 Rev. 4-12 C.G.S. § 46b-120 46b-149, 07-04 STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov PRINT OR TYPE. If necessary, attach additional information. TO: The Superior Court, Juvenile Matters Address of Court Docket number Name of child Address of child Sex Date of birth Child's race American Indian/Alaskan Native Indian tribe/reservation, if any Asian/Pacific Islander Hispanic Black Unknown School/grade White Other Yes No Name of mother Address of mother Mother's telephone numbers: Home: Name of father Work: Address of father Cell: Father's telephone numbers: Home: Name of guardian, if any Work: Address of guardian Cell: Guardian's telephone numbers: Home: Work: Cell: Complaint I believe that the above family is a family with service needs because it includes the child who: ("X" appropriate box(es)) A. Has run away from his or her parental home or other properly authorized and lawful place of abode without just cause. When (Date) For how long To where (If known) Previous history of running away "X" here if the child has been missing for more than twenty-four (24) hours at the time of this complaint "X" here if you have contacted the police and reported the child as missing. B. Is beyond the control of his or her parent(s), guardian or other custodian. (Describe behavior and date(s) of event(s)) C. Has engaged in indecent or immoral conduct. (Describe behavior and date(s) of event(s)) D. Is 13 years old or older and has had sexual intercourse with another person and the other person is 13 years old or older and not more than two years older or younger than the child. Additional Information Please provide information regarding the following, if available: Current mental health diagnosis of the child (If known) 1. Has the child received help for problem behaviors in the past? No No No Yes (when and where): Yes (specify): Yes (specify clinician's name): (Continued on back/page 2) American LegalNet, Inc. www.FormsWorkFlow.com 2. Does the child currently take any medications? 3. Does the child currently see a therapist? Additional Information - Continued 4. Has the child been in the hospital recently? No No No No No No No Assault others? Yes (specify dates and reasons): Yes (when): Yes (describe type and frequency): Yes (specify): Yes (specify how often): Yes (specify how often): Yes (describe and how often): Yes (describe and how often): Yes For how long Where 5. Has the Department of Children and Families been involved? 6. Is the child involved with substance abuse? 7. Has the child violated curfew (out past 11 p.m.)? 8. Does the child engage in verbal arguments in the home beyond simple talking back (i.e., screaming or swearing)? 9. Does the child engage in physical violence in the home? Damage property? No No When (Dates) 10. Has the child had previous out-of-home placements, including with other family members? Reason(s) Comments Use this space to provide comments and explanations that will help the court process this complaint. Complainant's signature Relationship or agency and title (if applicable) Date signed NOTICE: The child may not be placed in detention based on this complaint. JD-JM-120 (back/page 2) Rev. 4-12 American LegalNet, Inc. www.FormsWorkFlow.com