F.C.A.§ 251

General Form 13 (Order Directing Medical Examination) 12/97 At a term of the Family Court of the State of New York, held in and for the County of , at , New York on , 19

P R E S E N T: Hon. Judge ............................................................................ In the Matter of a Proceeding under Article of the Family Court Act

Docket No. ORDER DIRECTING MEDICAL EXAMINATION (OUTPATIENT)

.............................................................................. A petition under Article of the Family Court Act, sworn to on , having been filed in this Court in the above-entitled proceeding alleging that , 19

and the matter having duly come on to be heard before this Court; and IT APPEARING that this Court has jurisdiction over the petition and that (is a person within the jurisdiction of this Court) (is a parent or other person legally responsible for the care of a child who is within the jurisdiction of this Court); and IT FURTHER APPEARING that an examination of by a (physician) (psychiatrist) (psychologist) would serve the purpose of this Act (and the Director of an institution in the Department of Mental Hygiene, having been afforded an opportunity to be heard before this Court); it is therefore *(ORDERED that report for examination by a (physician) (psychiatrist)(psychologist) appointed, or designated for this purpose by the Court, at , New York, on , 19 , or at such other times and places as may be directed;) **(ORDERED that report to

GF-13 page 2

, a Department of Health facility in the City of New York maintained for that purpose, at , New York, on ,19 , or at such other times and places as may be directed for (physical)(psychiatric) (psychological)examination;) *(ORDERED that report to (a hospital maintained by (County) (State of New York) (a qualified private institution approved for such purpose), at , New York, on ,19 , or at such other times and places as may be directed for (physical) (psychiatric)(psychological) examination;) And it is further ORDERED that shall, within completion of such examination, submit a report thereof to this Court. *(And it is further ORDERED: days after the

.)
PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE LAW GUARDIAN UPON THE APPELLANT, WHICHEVER IS EARLIEST.

Dated:

19

ENTER

J.F.C. Check applicable box:

*Delete inapplicable provisions **Applicable only to New York City; delete if inapplicable.