CPS - LONG FORM
Agency involvement / removal / status
Name
First Name
Last Name
Your date of birth
-
Month
-
Day
Year
Date
Which best describes your relationship to the children you are reporting about.
Parent
Paternal grandparent
Maternal grandparent
Step parent
Other relative
Friend
Foster parent
Sibling
No relationship
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of your residence
Phone Number
-
Area Code
Phone Number
If you no longer live in the county where these events occurred, give the county and state where the investigation, removal, and court action occurred.
Name of the state agency
Sample Department of children's services.
Date of first involvement with CPS
-
Month
-
Day
Year
Date
Full Names and date of birth of all children involved with cps in your family. Please LIST them with their date of birth in order of their age with the oldest on top.
Sample Jane Doe Jan 5, 2010
Your relationship to the children listed above. If you need more room to explain please use the notes area below.
Sample Maternal grandmother
Notes on relationship to children. If you are not the parent of the children please list the names of the parents for each child
Date of the first removal of the child or children.
-
Month
-
Day
Year
Date
Describe the reason that the child or children were removed on the first occasion if more room is need use the notes entry for additional information.
Sample Alleged drug use by father.
Additional notes on the reason the children were first removed.
If you know or suspect who made a CPS referral regarding your children identify the person and the circumstances.
Sample Jack Spratt. Neighbor who complained about my dog.
Describe HOW the children were removed. Such, they were taken from the school, from my home at night, etc. Please give the detail that you recall such as what was told to the children, how the children reacted. If you need more space use the notes section below.
Sample Susie was taken from her school during the day without telling me.
Additional notes on describing HOW the children were removed.
Describe where the children were placed. Such as grandparents, aunt, fostercare. Give as much detail as you can. Such as foster care home located In----- if your children spent the night or days at the CPS office please include that detail. If you need more space use the notes section below.
Sample First night foster home in Wilson county
Additional notes on where your children were placed when they were removed.
State agency persons involved. Please identify by name and job description the persons with the state agency involved in the initial investigation and removal. Provide a short summary of their role. The details will come later. If you need more space use the notes section below.
Sample Jane Doe, cps investigator, first contact
Were your children removed with an ex parte order? In order words did a judge sign an order to remove the children WITHOUT a court hearing and WITHOUT your knowledge?
YES
NO
Other-see below
If you need to explain the above answer do so here.
Regarding the AUTHORITY relied on by the state agency used to remove your children- check all that apply.
Order signed by judge or magistrate
Ex parte order
Protection agreement
No order. Told me they did not need an order.
Brought law enforcement with them
None. They told me they did not need an order
Warrant
Were you given a copy of the order, warrant, protection agreement, or other document at the time of removal.
Yes
No
Other explain below
Explain whether or not you were provided documents
If you have a copy of the documents you were provided when your children were removed upload them here.
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Describe how you were given notice of your first court date. Include the names of persons involved.
Date of first court date after removal.
-
Month
-
Day
Year
Date
In some instances the parents or other parties have been summoned to court or served with papers to compel them to cooperate with an investigation. If this happened to you describe when this occurred and what you were compelled to do by the court or agency. If you need more space use notes below.
Additional notes about being compelled to cooperate.
After removal-describe what happened on the first court date after removal. Particularly tell if you had an attorney with you, if the judge heard evidence from the agency, if the judge made remarks regarding the state agency, you, or the children. State if the children were present and if the children had a guardian ad litem present. If you need more space see below.
Additional space to describe the first court appearance
Name of the court of your first court appearance
Sample Wilson County Juvenile. Court
Name of the judge on your first court appearance
Sample Judge John Jones
The name of the guardian ad litem appointed by the court.
Provide information about your legal representation at the first court hearing. Were you given a court appointed attorney, did you hire an attorney, or no representation. Provide the names and contact information of these attorneys.
Provide petitions for investigation or removal and court orders. You need to put these documents in chronological order of their occurrence. You may not know which documents go with which court appearance. If you don't just make sure they are in chronological order by dates.
Upload a File
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If you were required to attend any agency meeting or required to do anything by a state agency prior to removal please describe in detail. It is important to identify any documents you were required to sign, whether or not you were told you had to do drug screens classes, home inspections, anger management classes, or otherwise. Also explain if you had an attorney present, if you were appointed an attorney, or if you were informed of your right to an attorney. If you need more space use the space below.
Additional notes about your required cooperation prior to removal.
Date children were returned to parents or family placement?
-
Month
-
Day
Year
Date
Brief description of current status.
Have parental rights been terminated
Yes but on appeal
Yes final
Yes by agreement
Yes other
No
If parental rights have been terminated - were the children adopted by foster parents?
Yes foster parents
Not foster parents but other non relative
No but adopted by family
No
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