Free JV-225~2.OFM - California

JV-225

Your Child's Health and Education

Clerk stamps date here when form is filed.

To the social worker or probation officer: If the parent or guardian needs help completing this form, please ensure that he or she receives assistance. To the parent or guardian: Complete and sign this form. The information requested on this form is necessary to meet the medical, dental, mental health, and educational needs of your child. The court has directed you to provide your child's medical, dental, mental health, and educational information. The court has also directed you to provide your medical, dental, mental health, and educational information and, if you know, the same information about the other parent or guardian. If you need help, the social worker or probation officer will help you fill out this form. 1 Your name: Your relationship to child: Your home address: City: Your mailing address: City: Your telephone: Your child's name: a. Your child's date of birth: b. Where was your child born? City:

Fill in court name and street address:

Superior Court of California, County of

State: State:

Zip code: Zip code:

Clerk fills in case number when form is filed.

Case Number:

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c. Hospital: d. Your child's birth weight: State: Country:

Child's Health
1 3 Does your child have any physical or mental health challenges? Yes No If yes, is your child receiving any assistance, services or treatment for these problems? (Explain): a. Allergies: b. Injuries: c. Diseases: d. Disabilities: e. Other: f. Other: Is your child taking any medication? Yes No If yes, please list the medicines and explain why your child is taking them: Medication and dosage Reason for taking medication

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Date began

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When was your child last seen by a doctor? Date: Doctor's name: Doctor's office address (include city, state, zip code): Doctor's mailing address (include city, state, zip code): Doctor's telephone number:

Judicial Council of California, www.courtinfo.ca.gov Revised January 1, 2008, Mandatory Form Welfare and Institutions Code, § 16010

Your Child's Health and Education

JV-225, Page 1 of 5
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Case Number:

Child's name:
1 6 When was your child last seen by a dentist? Date: Dentist's name: Dentist's office address (include city, state, zip code): Dentist's mailing address (include city, state, zip code): Dentist's telephone number: List the names of all doctors, nurses, dentists, hospitals, clinics, and other health-care providers and healers who have seen your child within the past two years: Name Address (city, state, zip code) Date of last visit Reason for visit

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What doctor, nurse, dentist, hospital, clinic, or other person has your child's health records? a. Medical records: b. Dental records: c. Mental health records: When was your child's eyesight last tested? Date of examination: Who examined your child's sight: Address (include city, state, zip code): Telephone number: Does your child wear glasses? Does your child wear a hearing aid? Yes Yes No No

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Is your child covered by an insurance policy? a. Medical Yes No (If yes, specify insurance policy): b. Dental c. Vision Yes Yes No (If yes, specify insurance policy): No (If yes, specify insurance policy):

Child's Education
1 13 Before your child was removed from your home, what school did your child attend? Name of school: Address (include city, state, zip code): Yes No a. Is your child still allowed and able to attend this school? b. If no, did you agree to give up your child's right to remain at this school? Yes No c. Before removal, was your child receiving or had your child received any assistance or help at school or any assessments, evaluations, services, or accommodations to help your child with any physical, mental, or Yes learning-related disabilities or other special educational needs? No (1) If yes, what assessments, evaluations, services, or accommodations was your child receiving?

(2) Who gave your child these educational services?

Revised January 1, 2008

Your Child's Health and Education

JV-225, Page 2 of 5

Case Number:

Child's name:
1 13 d. If applicable, do you have a copy of your child's individualized education program (IEP), section 504 plan, individual family plan (IFP), or quality of life assessment? Yes No e. What language did your child first learn to speak? f. What is his or her primary language? g. What language do you most often use when speaking to your child? h. Has your child ever been identified as English proficient or as an English language learner by a school? Yes No i. Has your child ever been enrolled in a specialized program to learn English? 1 14 Yes No

List all other schools or day care your child has attended: School (name, city, state): School (name, city, state): School (name, city, state): School (name, city, state): Dates of attendance: Dates of attendance: Dates of attendance: Dates of attendance:

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a. What grade is your child in? b. Does he or she have any special needs? If yes, please describe: Yes No

c. If the child is three years old or younger, do you believe that the child may be eligible for services to help with motor, developmental, or other delays? If yes, explain why: What assessments, evaluations, services, treatment, or accommodations do you believe the child may need for the delay?

d. Do you believe the child may have a disability? If yes, please describe: What assessments, evaluations, services, treatment, or accommodations do you believe the child may need for the disability?

Revised January 1, 2008

Your Child's Health and Education

JV-225, Page 3 of 5

Case Number:

Child's name:
1 16 Has your right to make educational decisions for the child been limited? If yes, who has the right to make educational decisions for the child? Name: Relationship to child: Yes No

Biological Parent's Health and Education (You are required by Welfare and Institutions Code section 16010 to
provide this information about yourself. If you do not want to provide this information, please talk to your attorney.) 1 17 a. When were you last seen by a doctor and dentist? (1) What medical problems run in your family?

(2) Do you have medical problems or disabilities?

(3) What medications do you take? Medication

Reason for taking medications

b. What is your educational history? (1) School last attended (name, city, state): (2) Last grade completed: 1 18 a. If you know, provide the following information about your child's other parent: (1) Name of other parent: (2) Relationship to child:

Revised January 1, 2008

Your Child's Health and Education

JV-225, Page 4 of 5

Case Number:

Child's name:
1 18 a. (3) Other parent's medical problems and disabilities (Please include physical, mental, and learning problems):

(4) The child's other parent takes the following medications: Medication Reason for taking medications

(5) The following medical problems run in the family of my child's other parent:

b. My child's other parent has the following educational history: (1) School last attended: (2) Last grade completed: I declare under penalty of perjury under the laws of California that the information on this form is true and correct to my knowledge. This means that if I lie on this form, I am guilty of a crime. Date:

Type or print parent's/guardian's name

Parent/guardian signs here

Date:

Type or print social worker's name

Social worker signs here

Date:

Type or print probation officer's name

Probation officer signs here

Revised January 1, 2008

Your Child's Health and Education

JV-225, Page 5 of 5