Form KDOC-0094 "Juvenile Supervision Plan" - Kansas

What Is Form KDOC-0094?

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

Form Details:

  • Released on July 1, 2007;
  • The latest edition provided by the Kansas Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form KDOC-0094 by clicking the link below or browse more documents and templates provided by the Kansas Department of Corrections.

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Download Form KDOC-0094 "Juvenile Supervision Plan" - Kansas

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Juvenile Supervision Plan
Initial Date:
Review Date:
Juvenile:
Supervision Officer's Name:
Supervision Type:
Supervision Level:
Court Case No.
Committing Offences
Defense Attorney
Court of Sentence
_______________________________________________________________________________________________________
Domain: Family Circumstances and Parenting
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
______________________________________________________________________________________________________
Domain: Education/Employment
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
_______________________________________________________________________________________________________
Domain: Peer Relations
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
_______________________________________________________________________________________________________
Domain: Substance Abuse
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Page 1 of 14
State of Kansas
Kansas Department of Corrections
Form KDOC-0094
July 2007
Juvenile Supervision Plan
Initial Date:
Review Date:
Juvenile:
Supervision Officer's Name:
Supervision Type:
Supervision Level:
Court Case No.
Committing Offences
Defense Attorney
Court of Sentence
_______________________________________________________________________________________________________
Domain: Family Circumstances and Parenting
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
______________________________________________________________________________________________________
Domain: Education/Employment
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
_______________________________________________________________________________________________________
Domain: Peer Relations
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
_______________________________________________________________________________________________________
Domain: Substance Abuse
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Page 1 of 14
State of Kansas
Kansas Department of Corrections
Form KDOC-0094
July 2007
Responsivity:
_______________________________________________________________________________________________________
Domain: Leisure/Recreation
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
_______________________________________________________________________________________________________
Domain: Personality and Behavior
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
_______________________________________________________________________________________________________
Domain: Attitudes/Orientations
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
___________________________________________________________________________________________________
Domain: Other
Domain Score:
Problems Relating To Treatment:
Treatment Goals:
Objective(s):
Duration:
Responsibility:
Completed:
S/U
Strengths:
Responsivity:
_______________________________________________________________________________________________________
Page 2 of 14
State of Kansas
Kansas Department of Corrections
Form KDOC-0094
July 2007
II. IDENTIFYING INFORMATION
Juvenile
Last Name
First
Middle
______________________________
______________________________
______________
AKA(s)
___________________________________________________________________________________________
Date of Birth
Age
SSN
Race
________________
_________
_________________
_______
Height
Weight
Hair
Eyes
Gender:
M or
F
_________
_________
_________
_______
Address _____________________________
________________________________________________________
___________________________________________________________________________________________________
Phone(s): Home _________________ Work _________________ Other ______________________
Family Contact
Name (
)
last, first, middle
_____________________________________________________________________________
Address _____________________________
________________________________________________________
___________________________________________________________________________________________________
Phone(s): Home _________________
Work _________________
Other ________________
Removal Home
Y or
N
Relationship to Youth __________________________
Family Contact
Name (
)
last, first, middle
_____________________________________________________________________________
Address _____________________________
________________________________________________________
___________________________________________________________________________________________________
Phone(s): Home _________________
Work _________________
Other ________________
Removal Home
Y or
N
Relationship to Youth __________________________
Family Contact
Name (
)
last, first, middle
_____________________________________________________________________________
Address _____________________________
________________________________________________________
___________________________________________________________________________________________________
Phone(s): Home _________________
Work _________________
Other ________________
Removal Home
Y or
N
Relationship to Youth __________________________
Page 3 of 14
State of Kansas
Kansas Department of Corrections
Form KDOC-0094
July 2007
III. MEDICAL SECTION
(applicable only for CR, CM, ICJ, JCF)
Insurance: Y or N
Insurance Name and Address: _______________________
________________________________________________
Policy #: _____________________
________________________________________________
Medicaid Card: Y or N ID
Check if received copy of immunization record in case file
#_________________
Allergies:
_________________________________________________________________________________________________
Juvenile’s identified medical problems: _________________________________________________________
__________________________________________________________
__________________________________________________________
Physician(s) (
): ________________________________________________________________
name and address
________________________________________________________________
Diagnosis (s): _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Medication(s):
____________________________________________________________________________________________
____________________________________________________________________________________________
Physician(s) (
): _________________________________________________________________
name and address
______________________________________________________________________________
Diagnosis (s): _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Medication(s):
____________________________________________________________________________________________
____________________________________________________________________________________________
Page 4 of 14
State of Kansas
Kansas Department of Corrections
Form KDOC-0094
July 2007
IV. MENTAL HEALTH
(applicable only for CR, CM, ICJ, JCF)
Provider(s) Name:
______________________________________________________________________
______________________________________________________________________
Medication(s):
______________________________________________________________________
______________________________________________________________________
Documented Diagnosis: ____________________________________________________________________
____________________________________________________________________
Treatment(s): _____________________________________________________________________________
____________________________________________________________________________
Provider(s) Name:
______________________________________________________________________
______________________________________________________________________
Medication(s):
______________________________________________________________________
______________________________________________________________________
Documented Diagnosis: ____________________________________________________________________
____________________________________________________________________
Treatment(s): _____________________________________________________________________________
____________________________________________________________________________
Page 5 of 14
State of Kansas
Kansas Department of Corrections
Form KDOC-0094
July 2007
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