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Psychological Evaluation Template - DOC

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					                                                                                                                                     Santa Clara County
                                                                                                                                  Social Services Agency
                                                                                                             Department of Family and Children’s Services



 REFERRAL FOR JUVENILE DEPENDENCY COURT-ORDERED PSYCHOLOGICAL EVALUATION
SECTION I             REQUEST FOR EVALUATION
PLEASE FILL OUT THIS FORM COMPLETELY
Case (Minor’s) Last Name                              Case (Minor’s) First Name                DOB                  Case Number       Petition Number

Case (Minor’s) Last Name                              Case (Minor’s) First Name                DOB                  Case Number       Petition Number

Case (Minor’s) Last Name                              Case (Minor’s) First Name                DOB                  Case Number       Petition Number

Requesting Party:        Social worker       Attorney
Other:                                                                                                                Phone
Print Name:
                                                                                          Fax Number
Party/Dept. to be billed                                                                         Social Worker #:

PERSON(S) TO BE EVALUATED: (If more than five, attach a second sheet)
                     NAME                    REL. TO MINOR            D.O.B.             PHONE NO.                            ADDRESS
1.
2.
3.
4.
5.
NOTICE        * If all parties do not agree with the request for a psychological evaluation and with the questions to be addressed, the matter must be
resolved in Court.
                                                                                                 DATE                            *DIS-             NO
PARTY NOTICED                             NAME                             PHONE                                 AGREE
                                                                                               NOTIFIED                         AGREED         RESPONSE
Minor’s Attorney
Mother’s Attorney
Father’s Attorney
County Counsel
Social Worker
Other
*Basis for
Objection,
(if known):
You must provide a response to each of the questions below.
A. PURPOSE OF PSYCHOLOGICAL EVALUATION:


B. QUESTIONS TO BE ADDRESSED BY EVALUATOR (Questions cannot be changed or added to the Evaluation Request once the court has
     approved the questions):
     1.




Filling: Fastener 7 Under                                                                                          G:\template\forms\SCZ1671(c).doc
cc: Attorneys listed in Section                                  Referral for Juvenile Dependency Court-Ordered Psychological Evaluation – Rev. 05/03/04
                                                                                                                                                   1 of 3
C. SPECIAL CLIENT NEEDS (i.e., language, culture, medical, etc.);

D. DATE OF NEXT SCHEDULED HEARING:                            TIME:                  DEPARTMENT:
E. TYPE OF UPCOMING HEARING:       Jurisdiction   Disposition   Non-Reunification  6-Month Review
      12-Month Review   18-Month Review     366.26 Hearing    Post-Permanency Hearing    Visitation
       Placement    GAL   Other:
F. DATE EVALUATION MUST BE SUBMITTED TO EVALUATION COORDINATOR (10 days before hearing or
    other date specified by court):
G. HAS THIS PERSON BEEN THE SUBJECT OF A PREVIOUS COURT-ORDERED PSYCHOLOGICAL EVALUATION?
      No     Yes If yes, provide details, if known (date, evaluator, etc.) and explain why subsequent evaluation is
   necessary.


H. LIST SPECIFIC REPORTS OR OTHER DOCUMENTS TO ACCOMPANY REFERRAL (e.g., court reports,
police reports, medical reports, previous psychological evaluations, etc. NOTE: Any document or substantive
information not listed here cannot be submitted to the evaluator without prior court approval, except as provided
by the local rule cited below):
    1.




I. LIST PERSONS (AND PHONE NUMBERS) THE EVALUATOR IS TO CONTACT (e.g., natural parents, relatives,
foster parents, treating therapists, court advocate, etc. NOTE: Persons not listed here cannot be contacted by the
evaluator prior to completion of evaluation without prior court approval):
   1.




Santa Clara County Local Rule 4.2, § (F)(2): “No party or attorney in a dependency proceeding shall cause the minor to
undergo a . . . mental health examination or evaluation without court approval. The Court shall make the selection of the
person to perform any such examination. . . . This rule does not apply to the investigating. . . social worker prior to the
establishment of jurisdiction.”

Santa Clara County Local Rule 4.1, § (J)(8): “Where the Court has ordered a mental health or psychological evaluation of a
minor, the Court-approved evaluator shall be given a copy of the Court report relating to the minor, unless the Court makes a
specific order to the contrary in the referral.”




Filling: Fastener 7 Under                                                                             G:\template\forms\SCZ1671(c).doc
cc: Attorneys listed in Section                     Referral for Juvenile Dependency Court-Ordered Psychological Evaluation – Rev. 05/03/04
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SECTION II           COURT APPROVAL

                                  THE SUPERIOR COURT OF THE STATE OF CALIFORNIA
                                       IN AND FOR THE COUNTY OF SANTA CLARA
                                            JUVENILE DEPENDENCY COURT

Regarding Evaluation for:

The Juvenile Dependency Court has reviewed the above referral for psychological evaluation to assist in determining the
appropriate disposition in this matter and:
                         ______ Approves           _______ Disapproves the above referral.

                                        ORDER – Evidence Code § 730 Evaluation

IT IS HEREBY ORDERED that, pursuant to Evidence Code § 730, the above named persons be referred for psychological
evaluation. The Juvenile Dependency Court’s Evaluation Coordinator shall select the evaluator to conduct the evaluation,
and shall forward this referral and the accompanying documents described herein to the evaluator. Any health care or
mental health care provider subject to HIPAA or Welfare and Institutions Code §5328 who is listed in section (I) of the
attached referral is ordered to provide protected health information to the assigned evaluator pursuant to this court order.
The evaluation shall be completed and submitted to the Evaluation Coordinator at least 10 days before the next scheduled
hearing.

 ___________________________________                    _____________________________________________________
               DATE                                                       JUDICIAL OFFICER
SECTION III           REFERRAL TO COORDINATOR

Date of Referral: ____________________                         Report Due by: ____________________

Language need? ____________________                            Other special need: ____________________
SECTION IV            APPOINTMENT OF EVALUATOR(S)

Evaluator Assigned: ______________________________________________                     Date Assigned: ___________________

Address: _______________________________________________________                       Phone Number: ___________________

_________________________________________________________________________________________________
Maximum Hours Authorized: ______________

Evaluator Assigned: ______________________________________________                     Date Assigned: ___________________

Address: _______________________________________________________                       Phone Number: ___________________

_________________________________________________________________________________________________
Maximum Hours Authorized: ______________

Appointments are to be coordinated by social worker.

Notice: In order to be paid, the evaluator must return the following: The signed original and one copy of the report, this
referral form and an itemized billing to:

                                        Juvenile Court Evaluation Coordinator
                                        373 West Julian Street
                                        San Jose, CA 95110-2335


 __________________________________________________________                             ________________________________
               Evaluation Coordinator                                                                Date

Filling: Fastener 7 Under                                                                              G:\template\forms\SCZ1671(c).doc
cc: Attorneys listed in Section                      Referral for Juvenile Dependency Court-Ordered Psychological Evaluation – Rev. 05/03/04
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             REFERRAL FOR JUVENILE COURT-ORDERED PSYCHOLOGICAL EVALUATION

                                     INSTRUCTIONS FOR USE OF THE SCZ1671(C)
1.      SECTION I            REQUEST FOR EVALUATION

        The Social Worker or any Attorney of Record requesting the evaluation will:
        a. Supply all information requested in Section I.
        b. Provide (“notify”) other parties with a copy of the SCZ 1671(c) by mail, fax, or in person; note date of notification;
           note whether other parties agree or disagree with the request for a psychological evaluation; and note basis of
           objection, if known.
        c. Forward Referral Form to Court to review and approval.

2.      SECTION II           COURT APPROVAL

        The Court will:
        a. Review request.
        b. Approve or deny request, or set for hearing.
        c. Return signed form to requesting party.

3.      SECTION III          REFERRAL TO COORDINATOR

        The Requesting Party will:
        a. Complete Section III.
        b. Attach appropriate reports and documents listed on the SCZ1671(c).
        c. Social Workers complete and attach a SCZ414A payment voucher signed by supervisor.
        d. Forward packet to Evaluation Coordinator.

        For Non-Reunification (“Bypass”) Evaluation:

        e. Include 2 copies of the SCZ1671 referral form.
        f. Attach 2 Special Fund Request (SCZ414A) forms signed by supervisor.
        g. Attach 2 sets of reports and documents listed on the SCZ1671(c).

4.      SECTION IV           APPOINTMENT OF EVALUATOR

        The Evaluation Coordinator will:
        a. Review the packet.
        b. Confer with requesting party, if needed.
        c. Select evaluator(s).
        d. Verify availability of evaluator by telephone.
        e. Complete and sign Section IV.
        f. Return copy of SCZ-1671(c) referral form to requesting party.
        g. Forward copy of SCZ-1671(c) referral form, packet and protocol to selected evaluator(s).

5.      The Social Worker will coordinate the scheduling of appointments and forward copies of completed referral form to
        all attorneys.

6.      The Evaluator will submit the completed report and invoice to coordinator for review and approval.

7.      The Evaluation Coordinator will forward the evaluation report to the requesting party, and (for Social Workers) will
        submit the SCZ414A to the Social Worker’s Social Services Program Manager, or (for other requesting parties) will
        forward the invoice to the requesting party for necessary action and payment.

8.      The requesting party will distribute the evaluation report to all counsel of record immediately.

Filling: Fastener 7 Under                                                                                 G:\template\forms\SCZ1671(c).doc
cc: Attorneys listed in Section                         Referral for Juvenile Dependency Court-Ordered Psychological Evaluation – Rev. 05/03/04
                                                                                               INSTRUCTIONS FOR USE OF THE SCZ 1671(c)

				
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Description: Psychological Evaluation Template document sample