COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- a Calendar No. : JUDICIAL SUBPOENA : : SAN JUAN COUNTY CASA PROGRAM VOLUNTEER REFERENCE REQUEST : Defendant(s) : ...................................................... Re: _______________ Date: ______________ Dear _________________, THE PEOPLE OF THE STATE OF NEW YORK TO The above referenced applicant has applied as a volunteer to our program and has given you as a reference. CASA volunteers provide information on children who are abused and neglected, making recommendations to the Court as to a child's best interest. This reference form will be used to assess the applicant’s ability to carry out the role of a Court Appointed Special GREETINGS: Advocate. Selected applicants will receive a minimum of 20 hours of training and ongoing programCOMMAND YOU, information will enable us to being laid applicant's and each of youas WE supervision. Your that all business and excuses assess the aside, you ability to serve attend before a CASA envelope to return Court this Questionnaire. Thank you. , the Honorable Volunteer. Please use the enclosedat the located at County of in room INFORMATION RECEIVEDof , on the day WILL BE HELD20 , CONFIDENTIAL IN EVERY RESPECT)noon, and at any recessed , at o'clock in the (ALL or adjourned date, to testify and give evidence as a witness in this action on the part of the 1. In what capacity have you known the applicant? ________________________ For how long? ________________ 2. Your failure to comply with this subpoena is punishable ___aAverage ____ court and will make you liable to How well do you know the applicant? Very well ___Well as contempt of the party on whose___ Extreme Conflict ____ Doesn’t Apply_____ Good behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 3. Applicant's relationship to own children, if applicable? Good____ Average ___ Mild Honorable Witness,Conflict____ Extreme Conflict____ Doesn't Apply____ , one of the Justices of the Court 4. in County, day of , 20 Applicant's relationship to youth in general. (Check as many as are applicable) Understanding____ Impatient____ Patient____ Well Liked____ Friendly____ Distant_____ Stern_____ (Attorney must sign above and type name below) 5. Applicant's relationship with people in general. (Check as many as are applicable) Warm____ Shallow____ Sincere____ Cool____ Loyal____ Shy____ 6. Attorney(s) for How would you describe the applicant's friendships? (Check as many as are applicable) Many friends constantly changing____Few friends constantly changing____ Many friends loyal_____ Few friends loyal_____ Average_____ No friends____ 7. How would you rate applicant's health? Average____ Good____ Fair___Poor___ 8. Check as many of the following as describe the applicant. Domineering____ Cooperative____ Leader____ Follower____ Confident____ Happy____ Unhappy____ Friendly____ Considerate____ Stubborn____ Moody____ Assertive____ Res erved____ Lazy____ Telephone No.: Nervous___ Well-adjusted _____ Facsimile No.: Office and P.O. Address E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. 9. To what extent is this applicant aware of his/her shortcomings? : JUDICIAL SUBPOENA Plaintiff(s) Feels she/he has none_____ Strives to overcome them_____ Ignores them_____ Accepts them_____ Unknown____ -against: 10. Check those of the following that describe the applicant's temperament? Stable____ : Easily upset_____ Impatient_____ Patient_____ Hot-tempered_____ 11. Do you consider this applicant emotionally stable? Yes____ Usually____ If not, why not? ______________________________ Defendant(s) : : ...................................................... 12. Describe the applicant's ability to be flexible? Excellent____ Good____ Average____ Fair____ Poor____ 13. How THE STATE OF NEW YORK THE PEOPLE OF does the applicant assume responsibility? Excellent____ Good____ Average____ Fair____ Poor____ TO 14. How well does applicant finish projects or activities begun? Very well____ Well____ Average____ Fair____ Poor____ 15. How would you rate the applicant's ability to handle confidential information? Excellent___Good____Fair____ Poor____ Cannot maintain confidentiality___ GREETINGS: WE How would youYOU, that all business andbe objective, not laid aside, youbehavior or of you attend before COMMAND rate the applicant's ability to excuses being judging other's and each 16. , the Honorablelifestyles? at the Court locatedSomewhat bothered by lifestyles different than own____ Critical of at County of Very accepting of others____ in room , who live day of , at o'clock in the noon, and at any recessed others on the and act differently_____ , 20 or adjourned date, to testify and give evidence as a witness in this action on the part of the 17. Is this applicant critical or somewhat bothered by different ethnic backgrounds? No____ Yes ____ If yes, explain ___________________________________ 18. Your failure to complythe applicant ever hadis drug or alcohol problem? No____ Yes____ In your opinion, has with this subpoena a punishable as a contempt of court and will make you liable to If yes, explain ____________________________________________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 19. Has the applicant ever had his/her driver's license revoked or suspended? No_____ Not to my knowledge______ Yes _____ If yes, explain____________________________________ Witness, Honorable , one of the Justices of the Court 20. in County, day of 20 Has this applicant ever been accused, arrested,, or convicted of a crime? No_____ Not to my knowledge_______ Yes _____ If yes, explain______________________________ 21. In a few words, please summarize what your overall reaction or feelings are towards this applicant. (Attorney must sign above and type name below) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Attorney(s) for 22. Would you be comfortable having the applicant as an Advocate for a member of your family? Yes_____ No_______ If no, why not?_______________________ Office and P.O. Address SIGNATURE: ___________________________________ DATE: ________________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com