CASA Name Date Month
Supervisor Length of time as a CASA
Date appointed to the case Docket #

Name of child Date of birth
Time in foster care Date closed

Name of child Date of birth
Time in foster care Date closed

Name of child Date of birth
Time in foster care Date closed



Current placement of child(ren)
Own home With relative Foster home Group home
Adoptive home Shelter Hospital Residential facility
Independent living Other

Has there been any change in placement this month? Yes No
  If yes, from own home with relative foster home group home adoptive home shelter hospital residential facility independent living other to own home with relative foster home group home adoptive home shelter hospital residential facility independent living other
Did child(ren)'s school change as a result of placement change? Yes No
  If yes, from to
Has there been a change in state caseworker this month? Yes No
  If yes, from to
Are siblings placed together? (Only applies when siblings are also in care)
Yes No No siblings Siblings not in care
Is child(ren)'s placed in parish of home listed as permanent plan? Yes No
Have there been any incidents of abuse or neglect this month? Yes No
Are services being provided as specified in the last case plan? Yes No Partially

For current month contacts (number)

Title(s) of in-service training attended this month
(30 minutes in-service if you read the newsletter) Yes No
Was there a Family Team Conference held this month? Yes No Date
Were significant parties (including CASA) present at case planning?
Yes No Partially N/A
Does case plan specify visitation? Yes No
Has visitation been occurring as planned? Yes No Partially
Does case plan specify a permanent plan? Yes No
Permanent plan is Reunification Relative placement Adoption Long term foster care Independent living Other
Do you agree with permanent plan? Yes No
Was there a court hearing this month? Yes No Date
Did judge make "reasonable efforts determination"? Yes No N/A
Were there court continuances? Yes No If yes, how many
Did judge follow your recommendations? Yes No Partially N/A
Is inadequate shelter a contributing factor in the child(ren) placed or remaining in foster care?
Yes No Partially N/A
Date of next scheduled court hearing
Date of next scheduled Family Team Conference, staffing, etc.
(Date will be on the bottom of front page of case plan.)

Comments (Describe any successes you had or obstacles you are trying to overcome.)