2. Case Identifier/Number*
   Insert Case JC#
3. Case Status*

   1. Alleged
   2. Adjudicated
   3. N/A
5. CASA/GAL Name*
   Use your CASA/GAL name
6. Choose one*

   1. CASA/GAL
   2. Attorney: Pro Bono
8. Child Name*
   First Name, Last Name
9. Date of Birth*
   Date of Birth
11. Child Name 2
12. Child 2 Date of Birth
    Child 2 Date of Birth
14. Child Name 3
15. Child 3 Date of Birth
    Child 3 Date of Birth
17. Child Name 4
18. Child 4 Date of Birth
    Child 4 Date of Birth
20. Child Name 5
21. Child 5 Date of Birth
    Child 5 Date of Birth
23. Child Name 6
24. Child 6 Date of Birth
    Child 6 Date of Birth
26. Basis for Court Involvement:
28. Check all that apply*

    1. Dependancy
    2. Neglect
    3. Physical Abuse
    4. Sexual Abuse
    5. Emotional Abuse
    6. Crossover
    7. Custody/Visitation
    8. Other
29. Other Description
31. Type of Hearing
    -- Select One --Adjudication/DispositionAnnual ReviewCustodyDelinquencyDispositionMediationParental RightsPermanent CustodyPPLAVisitionOther
32. Other Description
34. Date of Complaint/Petition:
    Date of Complaint/Petition:
35. Date of GAL Appointment
    Date of GAL Appointment
37. Assigned to Judge
    -- Select One --CASA Office should insert JudgeDenise Navarre CubbonConnie ZemmelmanVisiting Judge:
38. Visiting Judge Name
40. Assigned to Magistrate
    -- Select One --AdyaCairlHutchesonJonesFieldRestivoRutledgeSorahOther:
41. Other Magistrate name
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field