Form AOC-JV-38 "Affidavit and Beyond Control of Parent Evaluation Form" - Kentucky

What Is Form AOC-JV-38?

This is a legal form that was released by the Kentucky Court of Justice - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2011;
  • The latest edition provided by the Kentucky Court of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form AOC-JV-38 by clicking the link below or browse more documents and templates provided by the Kentucky Court of Justice.

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Download Form AOC-JV-38 "Affidavit and Beyond Control of Parent Evaluation Form" - Kentucky

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AOC-JV-38
Doc. Code: ABCPE
CDW Referral No. _____________
Rev. 1-11
Juv Id: __________
l e x
Page 1 of 5
Case No. ____________________
e t
j u s t i t i a
Commonwealth of Kentucky
Court
[ ] Family
[ ] District
Court of Justice
www.courts.ky.gov
AffIdAvIT And BEyond ConTrol
County ______________________
of PArEnT EvAluATIon forM
FCRPP 40
This Beyond Parental Control Evaluation Form and Affidavit is mandatory and shall accompany any complaint/petition
of Beyond Parental Control submitted to the Court. No complaint/petition of Beyond Parental Control shall be filed with
a Court Designated Worker unless accompanied by this form, completed in full, to the best of the petitioner’s knowledge
and ability. If the answer to a given section is “None”, “Not applicable”, “Unknown”, that section shall be answered
accordingly.
This form shall by typed or printed and shall be clearly legible. Please use additional sheets if more space than
allotted is necessary to fully answer a question. Please attach any forms or documents relevant to this evaluation form.
Please include letters from doctors, therapists or other agencies that you have used to try to resolve the problems you
have had with your child.
1.
Child’s Information
Child’s Name: ______________________________________________
DOB: ____________
SS#: __________________________
Gender: q M q F
Race: _____________
School: _____________________________________ Grade: ______
Special Education: _____________________
Name of Parent(s) or Guardian (including step-parents): __________________________________________________
_______________________________________________________________________________________________
Address: _______________________________________________________________________________________
Home Phone: (
)_____________________
Work Phone: (
)_________________________
Child’s Address: __________________________________________________________________________________
Name(s), age(s) and relationship of other residents in the home: ____________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Are both parents actively involved even if they live in separate homes? ______________________________________
_______________________________________________________________________________________________
2.
Efforts Made by Parents/Guardians To Improve Beyond Control Behaviors
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3.
Which behavior(s) results in danger to the child or others (
i.e. drugs, alcohol, tobacco, gang involvement,
sexual activity, aggressive or violent behavior, destruction of property, self-harm (cutting or self-mutilation), physical
) ____________________________________________________________________________
violence, among others
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Reset Page 1
AOC-JV-38
Doc. Code: ABCPE
CDW Referral No. _____________
Rev. 1-11
Juv Id: __________
l e x
Page 1 of 5
Case No. ____________________
e t
j u s t i t i a
Commonwealth of Kentucky
Court
[ ] Family
[ ] District
Court of Justice
www.courts.ky.gov
AffIdAvIT And BEyond ConTrol
County ______________________
of PArEnT EvAluATIon forM
FCRPP 40
This Beyond Parental Control Evaluation Form and Affidavit is mandatory and shall accompany any complaint/petition
of Beyond Parental Control submitted to the Court. No complaint/petition of Beyond Parental Control shall be filed with
a Court Designated Worker unless accompanied by this form, completed in full, to the best of the petitioner’s knowledge
and ability. If the answer to a given section is “None”, “Not applicable”, “Unknown”, that section shall be answered
accordingly.
This form shall by typed or printed and shall be clearly legible. Please use additional sheets if more space than
allotted is necessary to fully answer a question. Please attach any forms or documents relevant to this evaluation form.
Please include letters from doctors, therapists or other agencies that you have used to try to resolve the problems you
have had with your child.
1.
Child’s Information
Child’s Name: ______________________________________________
DOB: ____________
SS#: __________________________
Gender: q M q F
Race: _____________
School: _____________________________________ Grade: ______
Special Education: _____________________
Name of Parent(s) or Guardian (including step-parents): __________________________________________________
_______________________________________________________________________________________________
Address: _______________________________________________________________________________________
Home Phone: (
)_____________________
Work Phone: (
)_________________________
Child’s Address: __________________________________________________________________________________
Name(s), age(s) and relationship of other residents in the home: ____________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Are both parents actively involved even if they live in separate homes? ______________________________________
_______________________________________________________________________________________________
2.
Efforts Made by Parents/Guardians To Improve Beyond Control Behaviors
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3.
Which behavior(s) results in danger to the child or others (
i.e. drugs, alcohol, tobacco, gang involvement,
sexual activity, aggressive or violent behavior, destruction of property, self-harm (cutting or self-mutilation), physical
) ____________________________________________________________________________
violence, among others
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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AOC-JV-38
Rev 1-11
Page 2 of 5
When did this behavior begin? _______________________________________________________________
4.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Why do you think the behavior(s) began? _____________________________________________________
5.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Is your child under any new medications which may cause mood or personality changes? ____________
6.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Who is your child’s doctor? date of last visit? _________________________________________________
7.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
8.
Have you discussed your concerns with your child? If so, what information did you learn that might be
helpful for the court to know?______________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
What privileges have you taken away? ________________________________________________________
9.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
10.
How have you attempted to structure your child’s time (
i.e. rules for after-school; set aside time for homework;
)? __________________________________________________________________
bed time; meal time; other routines
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
does your child have a curfew? If yes, time? __________________________________________________
11.
_______________________________________________________________________________________________
How many times per week does your child meet his/her curfew? __________________________________
12.
_______________________________________________________________________________________________
What is a typical consequence for missing curfew? _____________________________________________
13.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
What time does your child regularly go to bed? ____________________
14.
What time does your child regularly wake up? _____________________
15.
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AOC-JV-38
Rev 1-11
Page 3 of 5
16.
Please list the three (3) most significant influences on your child's behavior and how you feel your
child's beyond control behaviors are related to these. _________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
17.
Do you have any specific concerns about your child's friends? If so, please list those concerns. ______
_______________________________________________________________________________________________
list the places your child and his/her friends hang out. __________________________________________
18.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Is your child employed? Where? How many hours per week? What times of day? ___________________
19.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
does your child have a history of having trouble interacting with peers? If so, give examples: _________
20.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Is your child in school? If yes, name of school. If no, explain why. _________________________________
21.
_______________________________________________________________________________________________
22.
Please list the number of disciplinary actions taken against your child within the past school year:
__________ Suspensions __________ Detentions/Saturday School __________ Other: please specify: ________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Have your child’s grades changed? ___________________________________________________________
23.
Thinking back on the past school year, about how many days was your child absent from school? ______
24.
Have you ever been contacted by the school about his/her attendance?__________________________________
How are other family members responding to the child’s behaviors? ______________________________
25.
_______________________________________________________________________________________________
26.
What major events have taken place within the last couple of years? Who? When?
Death in the Family________________________________________________
Divorce _________________________________________________________
Major Illness _____________________________________________________
Change of Residence ______________________________________________
Lack of Permanent Residence _______________________________________
Friends Change __________________________________________________
School Change __________________________________________________
A change in the number of people in the household ______________________
Marriage ________________________________________________________
Change in parent’s employment _____________________________________
Other __________________________________________________________
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AOC-JV-38
Rev 1-11
Page 4 of 5
What forms of outside treatment have you tried? _______________________________________________
27.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Has your child ever been hospitalized for these behaviors? ______________________________________
28.
_______________________________________________________________________________________________
In a typical day, when is your child unsupervised? ______________________________________________
29.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
30.
does anyone in the child’s family use drugs/alcohol/tobacco? If yes, please describe.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
What would you like to see happen with your child? _____________________________________________
31.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
32.
What do you expect of the Court? What do you want the Court to do about the situation with your child?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
33.
family Information
Marital Status: [ ] Single
[ ] Married
[ ] Divorced
[ ] Widowed
[ ] Other _____________________
Employment: ___________________________________________________________________________________
Active EPO/DVO: [ ] Yes
[ ] No If yes, what county: _____________________________________________
Domestic violence unreported: _____________________________________________________________________
Frequency of Displacement/Homelessness: ___________________________________________________________
Child & Family medical conditions/illness: _____________________________________________________________
Other: _________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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AOC-JV-38
Rev 1-11
Page 5 of 5
34.
Parenting Issues:
Child refuses to follow house rules: __________________________________________________________
Sibling relationships: _____________________________________________________________________
Suspected gang involvement: ______________________________________________________________
Suspected drug involvement:_______________________________________________________________
Suspected alcohol use: ___________________________________________________________________
Other: ________________________________________________________________________________
35.
Agencies Involved:
Mental Health Professional/Comp Care: ____________________________________________________
Child Protective Services: ________________________________________________________________
Physician/Psychiatrist/Psychologist: ________________________________________________________
Counseling: __________________________________________________________________________
Family Intervention Services: ____________________________________________________________
Other: ______________________________________________________________________________
This form was:
Prepared by: _____________________________________________
________________________
Name
Relationship to Child
_______________________________________________________
________________________
Phone No. and Email
Date
Affidavit
I, _____________________________________, the undersigned Affiant, state that I have read the foregoing
and that the matters stated herein are true to the best of my information, knowledge, and belief.
____________________________________________
Signature
____________________________________________
Printed name
SWORN TO before me this _________ day of ___________________________, 2_____.
Name _________________________________________
Title ________________________________________
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