4406 - Case Set on Progress Call 4572 - Supportive Services Referral Order (06/30/16) CCDR N037 A IN RE: IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION Marriage Civil Union Legal Separation Allocation of Parental Responsibilities Visitation (Non-Parent) Support Parentage of: No.: ___________________________________ ______________________________________________________ Petitioner and ______________________________________________________ Respondent Calendar: ______________________________ Pre-Judgment Post-Judgment COOK COUNTY DEPARTMENT OF ADOPTION AND FAMILY SUPPORTIVE SERVICES IT IS HEREBY ORDERED that the matter is referred as follows: A. Cook County Department of Adoption and Family Supportive Services; G. W. Dunne Building, 69 W. Washington, Suit 818, Chicago, IL 60602: Telephone (312) 603-0550 Fax: (312) 603-9909 for Petitioner Respondent B. For the following: Home visit in Cook County out of Cook County ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ School Records (please provide name and address of school) ___________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Emergency ________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Monitoring (not to exceed one visit per month during a six (6) month period) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ C. Identification of Children, Parties, Attorneys and Child Representatives: Children's Full Name(s) D.O.B. ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ______________ ______________ ______________ ______________ ______________ Party with Whom Child(ren) Resides ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 2  4406 - Case Set on Progress Call 4572 - Supportive Services Referral Order (06/30/16) CCDR N037 B Petitioner: Name: _____________________________________ Address: ____________________________________ City/State/Zip: _______________________________ Date of Birth: _______________________________ Telephone (H): _______________________________ Telephone (W): ______________________________ Petitioner's Attorney: Atty. No.: ____________________ Name: _____________________________________ Address: ____________________________________ City/State/Zip: _______________________________ Telephone: __________________________________ Fax: _______________________________________ Respondent: Name: _____________________________________ Address: ____________________________________ City/State/Zip: _______________________________ Date of Birth: _______________________________ Telephone (H): _______________________________ Telephone (W): ______________________________ Respondent's Attorney: Atty. No.: ____________________ Name: _____________________________________ Address: ____________________________________ City/State/Zip: _______________________________ Telephone: __________________________________ Fax: _______________________________________ Child(ren)'s Representative/Guardian ad Litem/Attorney for Child: Atty. No.: ____________________ Name: _____________________________________ Address: ____________________________________ City/State/Zip: _______________________________ Telephone: __________________________________ Fax: _______________________________________ D. This matter is set for status on ________________________ , at ______ a.m/p.m. in Room ____________ (Status date should not be set prior to 67 days from the date of this Order.) ** The Court must fax this Order to the Cook County Department of Adoption & Family Supportive Services (312) 603-9909. Atty. No.: __________________________________________ Name: ____________________________________________ Atty. for: ___________________________________________ Address: ___________________________________________ City/State/Zip: ______________________________________ Telephone: _________________________________________ Primary Email: ______________________________________ Secondary Email: ____________________________________ Tertiary Email: ______________________________________ ENTERED: Dated: ___________________________________________ ________________________________________ Judge Judge's No. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 2 of 2