PERIODIC REVIEW REPORT(to be filled out by legal guardian/custodian and sent to the court)Docket Number:Child's Name:Date of Birth:Age:Name, child's Mother:Name, child's father:Address:Address:Phone:Phone:Custodian / Guardian's Name:Address:Phone:Initial Custody Date:I. Living ArrangementsWith whom is the child currently living?Address:Phone:Since (date):Who else lives in the home?What financial support or benefits are you receiving on behalf of the child?Social securityChild supportRUFAMedicaidOther:SSIWill the child continue to live with you until he/she is 18 years old? If so, have you consideredadoption or permanent guardianship? Why or why not?If the child will be leaving your home, what is the plan?Form 115Page 1 of 31/09 SML American LegalNet, Inc. www.FormsWorkFlow.com II. Family ConnectionsIs there an ongoing relationship between the child and his or her biological parents? With thechild's siblings? If so, what kind of contact do they have?Is there an ongoing relationship between the child and relatives? If so, who are they and how oftendo they have contact?Has there been a requirement that visits be supervised in the past, and have those visits beensupervised?III. HealthcareWhat medical visits has the child had since the last review?Date:Last dental exam: Dentist:Date:Last physical exam: Physician:Are immunizations up to date?Does this child have on-going or unmet medical needs? If so, how are they being addressed?IV. EducationWhat day care / pre-school / school does the child attend?Grade:Please attach a copy of the child's most recent report card.How is the child doing in school?Academically:Socially:Form 115Page 2 of 31/09 SML YesNo American LegalNet, Inc. www.FormsWorkFlow.com V. Key PeopleWho are the key people in this child's life?Relationship to ChildNameVI. Other Issues/DevelopmentsAre the concerns identified for the child at the time of the last review still an issue to be addressed?Have any new issues been identified requiring treatment or services?Are there any services the child needs that are unavailable to you?Would you like help in getting services for this child?Do you have any questions for the court? Are there any matters that need to be addressed at thecourt hearing? I affirm of my own knowledge that the facts and financial information I am stating aretrue and correct and that I am not omitting any information requested on this form. DateSignatureForm 115Page 3 of 31/09 SML American LegalNet, Inc. www.FormsWorkFlow.com