STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS SPECIFIC STEPS JD-JM-106 Rev. 1-11 C.G.S. §§ 46b-129(b), (d) & (j) P.B. Sec. 33a-6 www.jud.ct.gov Docket number(s) Address of court Superior Court for Juvenile Matters at Name(s) of child(ren) Name of mother Name of father Name of guardian (If applicable) Current disposition DCF worker Name of CIP monitor Phone Phone Name of Court Appointed Guardian Ad Litem Phone Specific Steps The Commissioner of the Department of Children and Families (DCF), the Petitioner in this case, and Name Relationship Mother Father (the Respondent), are instructed to comply with the following steps for the Respondent to safely retain or regain the custody of the child(ren) named above. (Connecticut General Statutes section 46b-129(j) and/or Practice Book section 33a-6.) The Respondent is ordered to: Keep all appointments set by or with DCF. Cooperate with DCF home visits, announced or unannounced, and visits by the child(ren)'s court-appointed attorney and/or guardian ad litem. Let DCF, your attorney and the attorney for the child(ren) know where you and the children are at all times. Take part in counseling and make progress toward the identified treatment goals: Parenting Individual Family Goals (specify): Accept in-home support services referred by DCF and cooperate with them. Submit to a substance abuse evaluation and follow the recommendations about treatment, including inpatient treatment if necessary, aftercare and relapse prevention. Submit to random drug testing; the time and method of the testing will be up to DCF to decide. Not use illegal drugs or abuse alcohol or medicine. Cooperate with service providers recommended for parenting/individual/family counseling, in-home support services and/or substance abuse assessment/treatment: Cooperate with court ordered evaluations or testing. Sign releases allowing DCF to communicate with service providers to check on your attendance, cooperation and progress toward identified goals, and for use in future proceedings with this court. Sign the release within 30 days. Sign releases allowing your child's attorney and guardian ad litem to review your child's medical, psychological, psychiatric and/or educational records. Get and/or maintain adequate housing and a legal income. Immediately let DCF know about any changes in the make-up of the household to make sure that the change does not hurt the health and safety of the child(ren). Get and/or cooperate with a restraining/protective order and/or other appropriate safety plan approved by DCF to avoid more domestic violence incidents. Attend and complete an appropriate domestic violence program. Not get involved with the criminal justice system. Cooperate with the Office of Adult Probation or parole officer and follow your conditions of probation or parole. American LegalNet, Inc. (continued) Print Form Reset Form www.FormsWorkFlow.com Take care of the child(ren)'s physical, educational, medical, or emotional needs, including keeping the child(ren)'s appointments with his/her/their medical, psychological, psychiatric, or educational providers. Cooperate with the child(ren)'s therapy. Make all necessary child-care arrangements to make sure the child(ren) is/are properly supervised and cared for by appropriate caretaker(s). Keep the child(ren) in the State of Connecticut while this case is going on unless you get permission from the DCF or the court to take them out of state. You must get permission first. Visit the child(ren) as often as DCF permits. Within thirty (30) days of this order, and at any time after that, tell DCF in writing the name, address, family relationship and birth date of any person(s) who you would like the department to investigate and consider as a placement resource for the child(ren). Tell DCF the names and addresses of the grandparents of the child(ren). Other: DCF Is Ordered To: 1. Take all necessary measures to ensure the child(ren)'s safety and well being. 2. Monitor the welfare of the child(ren) and the circumstances surrounding his/her/their care by the Respondent. 3. Provide case management services. 4. Develop periodic treatment/permanency plan and review it with the Respondent. 5. Refer the Respondent to appropriate services (see above) and, as otherwise needed, monitor his/her progress and compliance. 6. Provide respondent with written, dated notice of all referrals to service providers and retain copies of such notices for the court. 7. Implement reasonable recommendations made by service providers and/or evaluators in this matter, or obtain relief from the court. 8. Within thirty (30) days of the receipt of written notice by the respondent, complete the investigation and consideration of any person(s) whom the respondent has properly identified as a placement resource for the child(ren). 9. Within thirty (30) days, complete the investigation and assessment of any relative identified as a placement resource for the child. 10. Evaluate home of following person(s) as potential placement for child(ren): 11. In a Domestic Violence case, assist in developing, implementing and monitoring an appropriate safety plan. 12. Advise all parties of any changes in the child(ren)'s placement. 13. During the time DCF has custody of the child(ren), DCF shall keep the child(ren)'s attorney and/or guardian ad litem informed in writing of the child(ren)'s location, placement and contact information. 14. Provide releases to a child's attorney and guardian ad litem to review the child's medical, psychological, psychiatric and/or educational records if child is committed. Other: Authorized CIP Monitor Contacts: DCF Worker Counselor or Clinic Foster Parent or Institution Child's/Youth's School Other: Approval And Order The court approves and orders the above steps as preliminary specific steps. This order shall remain in effect until the court orders final specific steps. Date signed Signed (Judge) Or The court approves and orders the above steps as final specific steps that are part of the disposition of the above matter. Date signed Signed (Judge) I agree to cooperate with the conditions approved and ordered by the court and I understand that if I do not follow these steps the existing order or disposition may be changed. I understand that if I do not follow these specific steps it will increase the chance that a petition may be filed to terminate my parental rights permanently so that my child may be placed in adoption. I understand that I should contact my lawyer and/or DCF worker if I need help in reaching any of these steps. Date signed Signed (Respondent) On behalf of DCF, as the Assistant Attorney General or Principal DCF Attorney representing the petitioner, I acknowledge that I have read these preliminary or final specific steps and DCF hereby agrees to cooperate with the above condition(s) approved and ordered by the court. Date signed Signed (Attorney) JD-JM-106 Rev. 1-11 (Page 2) Print Form Page 2 of 2 Reset Form American LegalNet, Inc. www.FormsWorkFlow.com