Free Microsoft Word - APPLICATION REVISION.Jan 2009 - California

LOS ANGELES SUPERIOR COURT PRIVATE CHILD CUSTODY EVALUATORS REFERRAL LIST
Application PLEASE COMPLETE ALL SECTIONS AND ATTACH YOUR RESUME. (Please note that any information provided on this form may be released to the public.) Name: Business Address: Business Telephone: E-Mail Address: Fax:

Do you: Speak Read Write any language other than English fluently? Yes No If yes, indicate language/s: LICENSE AND EXPERIENCE Professional License #: (Attach a copy of license.) Number of years performing child custody evaluations: Number of child custody evaluations performed: Do you perform brief assessments: Yes No FEES Fee per hour or fee per full evaluation: (Please attach a sliding scale, if applicable.) Per hour: Per evaluation: Additional costs for a full evaluation (e.g. for psychological testing): Typical cost of a full evaluation: (Do not include cost for court testimony or deposition.) Typical cost for a brief assessment, if applicable: Do you accept pro bono work? Cost for court appearance? PROCEDURES Do you perform psychological testing? Do you make home calls? OTHER INFORMATION Are you currently being charged, or have you ever been charged, with any violation(s) of law other than minor traffic violations? Yes No If yes, explain below or attach your explanation. Year Obtained:

Areas of specialty: (Optional) References: (Optional) DOMESTIC VIOLENCE UPDATE
The Family Code states that no person can be appointed by the Court to perform a child custody evaluation under Evidence Code 730 or Family Code §3111 unless the person has completed the domestic violence training requirements set forth in CA Rule of Court 5.230. No one will be placed on this list unless written proof of this training requirement has been fulfilled and is submitted to the List Administrator.

12 hour training in compliance with 5.230 received: (Certificate of attendance required.) Date: Location: Current 4 hour annual update training: (Certificate of attendance required.) Date: Location

Signature: _________________________________
Rev.1/09

Date: _________________________

PRIVATE CHILD CUSTODY EVALUATORS REFERRAL LIST
Declaration
I declare under penalty of perjury that: I have performed five child custody evaluations within the last three years. I have read the California Rules of Court Section 5.230 (Standards of Practice for Court-Connected Child Custody Evaluations) and the Los Angeles Superior Court Rule 14.21 (Private Child Custody Evaluators). I am in compliance with all training required for child custody evaluators by statute, rule of court, or local rule. I am covered by malpractice insurance and have attached a copy of my policy. I understand that it is my responsibility to submit to the Court a copy of my policy each year thereafter. I will notify the list administrator within two weeks of my license being revoked or suspended. In the event I am arrested or have criminal charges brought against me, I will notify the list administrator within one week of the arrest or charge. I understand that I am required to file the Family Law form, FL-326, within 10 days of appointment, in each case where I have been appointed. I understand that any evaluation ordered through this list must be completed and mailed within 10 weeks of receiving the appointment and desired deposit, unless extenuating circumstances arise. If an extension is required, the evaluator will notify the court, both parties, and the list administrator by letter. Reasons for the extension are to be described in the letter. I understand that to maintain my inclusion on the list, I must submit this Declaration, evidence of my malpractice insurance, evidence of completion of DV training, and a copy of my current clinical license annually. Failure to submit these documents may result in removal from the list. I understand that the Court may remove me from the referral list at any time upon written notification to the evaluator. Reasons for removal may include, but are not limited to the following: (a) (b) (c) (d) failure to remain current on training mandated by statute, California Rule of Court, and/or Los Angeles Superior Court Local Rule; submission of work that does not meet the standard of practice for court evaluator (Cal. Rules of Court, Rule 5.230); failure to submit work in a timely fashion; consistent refusal to accept court referrals. _____________________ (Date)











______________________________ (Name)
Rev. 1/09