RepresentYou.com | Secure Case Submission System

Contact Information

Name*

FirstLast

Address

Street AddressAddress Line 2CityStateZIP Code

Phone

Secondary Phone

Email*

General Information

City where the incident occurred*

County where the incident occurred*

State where incident occurred*

Date your child/children was taken*

Is the case still open?

Yes
No

If not, when was the case closed?*

Was your child/children returned home?

Yes
No

If yes, when was your child/children returned?*

Has any member of your household abused your child/children?

Yes
No

Please describe to the best of your ability the details of the abuse

Were you homeless when your child/children were taken?

Yes
No

Were you incarcerated (in jail or prison) when your child/children were taken?

Yes
No

Legal History

Do you have any arrests or convictions?

Yes
No

If so, please explain all arrests or convictions

Have you ever broken the law in front of your child/children? This includes domestic violence, use of Marijuana, DUI arrests, etc.

Yes
No

Legal Documents

Was a petition filed in your case?

Yes
No
Do not know

Do you have a detention report?

Yes
No
Do not know

If you answered no to any of the above questions, are you willing to get the document(s) listed above and send them in?

Yes
No

Just Cause

Was your child/children taken from you for no reason?

Yes
No

Why did child services take your children? What were you accused of?

Essential Provisions for Child or Children

Neglect is frequently defined in terms of a failure to provide for the child's basic needs—deprivation of adequate food, clothing, shelter, supervision, or medical care. Neglect laws often exclude circumstances in which a child's needs are not met because of poverty or an inability to provide.

Select all that you provided to your child:

Please enter the name of the doctor or clinic that attended to your child/children

Please enter the name of the school your child/children attended

Reasonable Efforts

What did child services do to help you keep your children?

Did child services try or make any effort to keep you together with your child?

Yes
No

Did child services offer you any services before they took your child/children?

Yes
No

Did child services offer information about non-profit organizations, counseling, or support?

Yes
No

Legal Proceedings

Do you know if you had a trial or a hearing?

Trial
Hearing
Do not know

Did a social worker take the witness stand and testify against you?

Yes
No
Do not know

Did you have a lawyer?

Yes
No
Do not know

Did you hire a lawyer privately or did the court appoint you an attorney?

Private lawyer
Court-appointed lawyer
Do not know

What did your lawyer tell you?

Did your lawyer ask you to "plea" or take a “deal” such as a “case plan”?

Yes
No
Do not know

Have you or are you currently taking classes as part of a "deal", "case plan", or "plea"?

Yes
No

Classes include parenting, anger management, and drug education, among others.

If you have or are currently taking classes, have you completed these classes with success?

Yes
No

Foster Care Abuse

Was your child/children abused in foster care?

Yes
No
Do not know

If your child/children was abused in foster care, check all locations where abuse took place:

Please select the type of abuse your child/children were subjected to:

Sexual abuse
Physical abuse
Psychological abuse
Neglect

Please describe to the best of your ability the details of the abuse

Who abused your child/children after your child/children was taken from you?

You may select more than one if necessary

If a foster parent abused your child, did his or her spouse know about the abuse?

Yes
No
Do not know

Please explain who else abused your child/children

Do you have evidence of abuse in foster care?

Yes
No

Please describe the evidence you have of abuse in foster care

Additional Information

How has this experience affected your emotional and physical health?

Please enter any additional information that you feel is relevant to your legal matter. Feel free to enter as much or as little information as you wish.

Child Services and Foster Care Information Form