Date Prepared Name of Social Worker Telephone Number (Social Worker) For FCA Use Only: Date Received Time Received Cumberland County Family Court 96 Hour Report Court File Number Name of Juvenile (As Appears On Petition) NOTICE TO DSS: THIS FORM SHALL BE COMPLETED AND PRESENTED TO THE ASSIGNED JUVENILE CASE MANAGER WITHIN 96 HOURS OF THE FILING OF A PETITION. CHILDREN (1) (2) (3) List all children by Full Name with DOB in age sequence order commencing with youngest child. Name DOB Name DOB Name DOB Name DOB Name DOB Name DOB Name DOB Name DOB Name DOB Name DOB RESPONDENTS List all respondents by full name and indicate the relationship of each to the child(ren). Mother Name Biological Father Name Legal Father Name Putative Father Name Step-parent Name (Relationship) Caretaker Name Other (Relationship) Other (Relationship) Other (Relationship) Other (Relationship) S YNOPSIS OF PRESENT INVOLVEMENT Provide a brief statement of the current case. ORIGINAL - FAMILY COURT OFFICE/ JUVENILE CASE MANAGER COPY - DSS ATTORNEY CCLF-FC(J)-001 Rev. 11/00 >>>> 2 PRIOR INVOLVEMENT WITH DEPARTMENT OF SOCIAL SERVICES List any and all prior involvement, to include substantiated or unsubstantiated investigations. TREATMENT HISTORY List any and all treatment services the family has received, from whom they received the services, and when the services occurred. (Provide present treatment and prior treatment.) CCLF-FC(J)-001- Side Two Rev. 11/00