Free State of Minnesota - Minnesota

State of Minnesota
County

District Court
Judicial District: Court File Number: Case Type: Parental Notification

Select County

In the Matter of the Petition of:

Report of the Guardian Ad Litem or Petitioner

Date of Birth: I. MEDICAL INFORMATION 1. Has the Petitioner been examined by a physician? Date: 2. 3. 4. Have the abortion procedures and the medical risks been explained? Have the aftercare procedures been explained and understood? Has the Petitioner been informed and does Petitioner understand what to do if medical complications occur? Has the Petitioner given a true statement of her medical history to the physician? Did Petitioner's physician advise her of any additional risks to her health as a result of her medical history? Has the Petitioner given informed consent to the abortion? Yes Yes No No Yes No

Yes

No

5.

Yes Yes

No No

6.

7. II.

Yes

No

COUNSELING INFORMATION 1. Has Petitioner received counseling regarding having an abortion? If yes, name and agency of counselor; Yes No

2.

Has Petitioner received counseling as to pregnancy alternatives? a. abortion b. adoption Yes Yes
Rev 01/02-D www.courts.state.mn.us/forms

No No

JUV202

State

ENG

Page 1 of 4

c. marriage d. single parenthood 3. Does Petitoner feel she needs more counseling as to her decision to a. have an abortion? Has Petitioner been counseled as to possible emotional and psychological a. Problems she may experience after the abortion? Has Petitioner been counseled as to the methods of contraception that a. are available?

Yes Yes

No No

Yes

No

4.

Yes

No

5.

Yes

No

III.

PERSONAL INFORMATION 1. 2. 3. Does Petitioner wish to have an abortion? Has Petitioner been coerced by any other party as to this decision? Petitioner elects not to notify her parent(s) because: Yes Yes No No

4. 5.

Does Petitioner live with her parents? What is Petitioner's source of financial income?

Yes

No

6. 7. 8. 9.

Is Petitioner attending school? Grade What is the highest school grade level Petitioner has completed? Is Petitioner employed? Place of employment:
Address

Yes

No

Yes

No

Job title:

10.

What are Petitioner's plans for the future (schooling, employment, etc.)?

JUV202

State

ENG

Rev 01/02-D

www.courts.state.mn.us/forms

Page 2 of 4

11.

State any additional information Petitioner wishes to bring to the court's attention relative to the proposed abortion:

Dated: Guardian Ad Litem on behalf of Petition or Petitioner

Relationship to Minor

JUV202

State

ENG

Rev 01/02-D

www.courts.state.mn.us/forms

Page 3 of 4

IV.

RECOMMENDATION OF THE GUARDIAN AD LITEM A. Authorization to the physician without parental notification is recommended because:

B.

The minor is mature and capable of giving an informed consent, as evidenced by:

C.

The minor is not mature, but the proposed waiver of parental notification is in her best interests because:

D.

It is not recommended that authorization be granted because:

Dated: Guardian Ad Litem

JUV202

State

ENG

Rev 01/02-D

www.courts.state.mn.us/forms

Page 4 of 4