Division COMMONWEALTH OF MASSACHUSETTS Docket No. Juvenile Court Department PERMANENCY MEDIATION INTAKE FORM (Attach a copy of the Order for Screening Conference) 1. Case Name: Care and Protection of: ___________________________________ Case Status: Pre-Trial Date: ________________ Trial Date(s): ________________ Next Court Date: ______________ Event: ___________________ 2. Name of Court Contact Person:_______________________________________ Tel No. __________________________ Fax No: ______________________ 3. Mother’s Name: ____________________________________________________ City/State of Residence: ______________________________________________ Primary Language: __________________________ Interpreter Needed: ________ Attorney’s Name:____________________________ Attorney’s Address: __________________________________________________ Tel No. __________________________ Fax No: ______________________ 4. Father’s Name: _____________________________________________________ City/State of Residence: ______________________________________________ Primary Language: __________________________ Interpreter Needed: ________ Attorney’s Name:____________________________ Attorney’s Address: __________________________________________________ Tel No. __________________________ Fax No: ______________________ Father of: ___________________________ 5. Father’s Name: _____________________________________________________ City/State of Residence: ______________________________________________ Primary Language: __________________________ Interpreter Needed: ________ Attorney’s Name:____________________________ Attorney’s Address: __________________________________________________ Tel No. __________________________ Fax No: ______________________ Father of: _____________________________ 6. Name of other person participating in mediation (e.g. foster parent, preadoptive parent): __________________________________________________________________ City/State of Residence: ______________________________________________ Primary Language: __________________________ Interpreter Needed: ________ Attorney’s Name:____________________________ Attorney’s Address: __________________________________________________ Tel No. __________________________ Fax No: ______________________ 7. (N O T E S ) Department of Social Services: Attorney’s Name: ___________________________________________________ Address: __________________________________________________________ Tel No. __________________________ Fax No: ______________________ On-going Social Worker’s Name: _____________________________________ Area Office: ___________________________ Telephone No. ________________ Adoption Worker’s Name: ___________________________________________ Area Office: ___________________________ Telephone No. ________________ JV-Permanency Mediation Intake Form (06/2008) American LegalNet, Inc. www.FormsWorkFlow.com Juvenile Court Permanency Intake Form, Page 2 8. Child’s Name: ______________________________________________________ Date Of Birth: _________________________ Attorney’s Name:_____________________________________________________ Attorney’s Address:___________________________________________________ Tel No. __________________________ Fax No:_______________________ 9. Child’s Name: ______________________________________________________ Date Of Birth: _________________________ Attorney’s Name: ____________________________________________________ Attorney’s Address:___________________________________________________ Tel No. __________________________ Fax No: ______________________ 10. Child’s Name: ______________________________________________________ Date Of Birth: _________________________ Attorney’s Name:____________________________ Attorney’s Address: __________________________________________________ Tel No. __________________________ Fax No: ______________________ 11. Child’s Name:_______________________________________________________ Date Of Birth: _________________________ Attorney’s Name:_____________________________________________________ Attorney’s Address:___________________________________________________ Tel No. __________________________ Fax No:_______________________ 12. Child’s Name: ______________________________________________________ Date Of Birth: _________________________ Attorney’s Name:_____________________________________________________ Attorney’s Address:___________________________________________________ Tel No. __________________________ Fax No:_______________________ Comments or Instructions: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Fax this form, the ADR Referral Form and the Order for Screening Conference to: 1) Massachusetts Families for Kids: Attention Julia A. B. Pearson, fax: 617-445-4796. If you have any questions regarding the mediation process or the status of this case. Contact information: Julia A. B. Pearson at 617-989-9446, 2) Case Manager James Morton, Esq., Juvenile Court Administrative Office, fax: 617-788-8965. Contact information: James at 617-788-6550. American LegalNet, Inc. www.FormsWorkFlow.com