Address: Phone: Parent Child-in-Care Family Member. Are your children in care? Yes No CFS Agency: Name of Social Worker (s) 1. DOB 2.

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1 Name: Date: Date of Birth (m/d/y): Address: Phone: Are you a: Parent Child-in-Care Family Member Service Agency CFS Employee Other Membership First Nation: Are your children in care? Yes No CFS Agency: Name of Social Worker (s) Please list children: 1. DOB 2. DOB 3. DOB 4. DOB 5. DOB 6. DOB 1. How many children do you have that are in care? 2. How long have the children been in care? 3. Reason provided for apprehension 4. Why are you seeking advocacy? 5. What is the current status of your Child Welfare file(s)? Voluntary Placement Agreement Surrender of Guardianship Independent Living Temporary Permanent Ward Extended Care Other

2 6. Did you receive a Case Plan from the CFS Agency? Yes No Please explain. 7. What steps have you taken to get your children returned? 8. Please tell us about your experience with CFS so far? 9. Did you receive preventative supports to assist you with your children prior to your children being apprehended? Please explain. 10. Did CFS accurately explain the process that was to be followed? Yes No Please explain the process that was explained/followed.

3 Please write the timeline of your interactions with CFS. Take your time and best recall the moments of your experience so far. Please provide the dates that you remember and any documentation that was provided to you. You can make a timeline on this sheet and write further details on the following page.

4

5 Step Parent Step Parent If you have different fathers for your children, please write the fathers name below the box. ( if applicable) Name: Name: Name: Relationship: Relationship: Relationship: Emergency Contact Person #1 Emergency Contact Person #2 Are your children placed with family? Yes No If yes, who? If no, please explain:

6 The following questions are personal in nature as we would like to best support in whatever way necessary. The more information we have the better we can strive to meet your needs. If there are any questions that you feel are uncomfortable, please do not feel that you have to answer them. The information that we are gathering is not to judge you, but rather to find the best way to support you. 1. Are you married Common Law Single 2. What is your highest level of education? Please circle. Grade College University Please describe your educational experience. 3. Have you or a family member ever: Attended Residential School Yes No Been in CFS Care Yes No Adopted in the 60 s Scoop Yes No Faced Trauma or Tragedy Yes No Experienced Family Suicide Yes No If you answered Yes to any of the above questions, please describe. 4. Do you currently have thoughts of self harm or thoughts of suicide? Yes No If yes, please explain. 5. Do you have access to an Elder, Counsellor, or positive support person? Yes No 6. Would you like us to connect you with a: Elder Counsellor Priest/Minister Psychologist

7 7. Do you have any disabilities or health concerns? Yes No If yes, please describe. 8. Have you ever been diagnosed with any of the following? FASD Mental Illness Anxiety Depression Schizophrenia Bipolar If you have checked any of the above, please describe the support you are/have received to address the effects. 9. Age of first experience with: Alcohol Drugs 10. Do you feel you have an issue with addiction Yes No If you answered yes, please describe. (To what? How long?) 11. How has drugs or alcohol affected your life? 12. If you feel that you have an issue with drugs/alcohol, would you like to receive treatment, support or counselling? Yes No If yes, what support would you like for yourself? 13. Are you currently or have you previously been employed? Yes No If yes, briefly describe.

8 14. Do you have a Criminal Record? If so, please describe. 15. Have you ever been accused of Child Abuse? Yes No If yes, please explain the circumstances. 16. What kind of support would you need in order to see positive change in your life? 17. What kind of special gifts or talents do you have? Please describe. _ 18. Would you be interested in being apart of a Support Group? Yes No - Ernest Daniels 19. If you could wake tomorrow and everything was just the way you wanted it to be, what would that look like for you? _

9 Please write any additional information that you would like to share or attach any documentation that you feel may be important to your file.

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