Caregiver'S Report To The Court
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1
2Caregiver’s Report to the Court
Child’s Name:
Legal Case Number:
Hearing Date:
County with Legal Jurisdiction:
Child’s Assigned Social Worker:
Caregiver Name/Person providing information:
Please return Caregiver Report Form (via email, US Postal Service or in person) to the child’s assigned social
worker and/or guardian ad litem.
TOPICS:
1. Child’s strengths, hobbies, gifts, talents, participation in extra-curricular activities/events:
2. Child’s social interaction with caregiver family, peers and siblings:
3. Child’s school progress and adjustment:
4. Child’s physical health (state results of medical and dental appointments):
5. Child’s emotional health and well-being ( counselor or therapist appointment schedule):
CAREGIVER REPORT TO THE COURT
DSHS 15-313 (REV. 10/2011)
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