INTERSTATE COMPACT FOR JUVENILES 

 

FORM VIII

Home Evaluation Report Form 

ending State: 

     

   

 

Receiving State: 

     

   

uvenile’s Name: 

           

  DOB: 

           

  Case # 

           

 Supervision recommended 

 

 

 Supervision not recommended 

 

            

ROPOSED (cid:53)(cid:40)(cid:54)(cid:44)(cid:39)(cid:40)(cid:49)(cid:38)(cid:40)(cid:3)(cid:40)(cid:57)(cid:36)(cid:47)(cid:56)ATED: 

ame: 

           

ddress: 

     

   

  Relationship:  

           

rimary Phone #: 

     

     

     

               Secondary Phone #: 

     

     

     

OME/NEIGHBORHOOD/PEERS (physical description, criminal/gang activity, etc.): 

     

   

AMILY STATUS (composition, interactions, at-risk family members, attitude, support capabilities, etc.):

     

   

 

  

  S

  J

 

  P

  N

  A

    P

  (cid:3)   

       

      

                     

 

  H

         

         

  F

         

ICJ HOME EVALUATION REPORT | Rev. 02-01-16                    Page 1 of 3 
 

 FAMILY EMPLOYMENT/FINANCIAL RESOURCES (If employed, who will supervise the juvenile):   

   

LEGAL HISTORY OF FAMILY (current charges, probation or parole status). 

   

PROPOSED PLAN (school/employment, court-ordered conditions, treatment needs).   

ICJ HOME EVALUATION REPORT | Rev. 02-01-16                    Page 2 of 3 
 

 

 

        

 OTHER COMMENTS (recommendations, questions, concerns): 

(Evaluating worker – printed name) 

 

 

 

(Supervisor – printed name) 

         

 By checking this box, I confirm the validity of the
 information contained within this form.
 

         

 

           
             (Date) 

 

 

 By checking this box, I confirm the validity of the
 information contained within this form.
 
 

           

 

 

           

   (Date) 

or ICJ Official use only: 

 Supervision approved   

 Supervision denied 

             

__________________________ 

 

 

 

 

 

 

 

 

  

(Date)

____________________________________________________ 

(Compact Official Name) 

 By checking this box, I confirm the validity of the
 
 information contained within this form.

 

ICJ HOME EVALUATION REPORT | Rev. 02-01-16                    Page 3 of 3 

 

 

 

          

 

  

REPORTING INSTRUCTIONS: 

ame: 

     

   

Agency: 

     

   

ddress: 

     

   

Telephone # 

     

   

 

 

         

         

         

 

       

     

    

   N

  A

   

 

   

  

    F

 

 

  _