Form Jv 225 – Fill Out and Use This PDF

Child’s Health

4 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			Date began

5When 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:

6When 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:

7List 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

8What doctor, nurse, dentist, hospital, clinic, or other person has your child’s health records?

a.Medical records:

b.Dental records:

c.Mental health records:

9When was your child’s eyesight last tested?

Date of examination:

Who examined your child’s sight:

Address (include city, state, zip code):

Telephone number:

10	Does your child wear glasses?	Yes	No
11	Does your child wear a hearing aid?	Yes	No

12Is your child covered by an insurance policy?

a. Medical	Yes	No (If yes, specify insurance policy):
b. Dental	Yes	No	(If yes, specify insurance policy):
c. Vision	Yes	No	(If yes, specify insurance policy):

Child’s Education

13Before your child was removed from your home, what school did your child attend?

Name of school:

Address (include city, state, zip code):

a.	Is your child still allowed and able to attend this school?	Yes	No
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

learning-related disabilities or other special educational needs?

Yes

No

(1)If yes, what assessments, evaluations, services, or accommodations was your child receiving?

(2)Who gave your child these educational services?

13d. 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?		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?

16 Has your right to make educational decisions for the child been limited?

Yes

No

If yes, who has the right to make educational decisions for the child?

Name:

Relationship to child:

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.)

17a. 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:

18a. If you know, provide the following information about your child’s other parent:

(1)Name of other parent:

(2)Relationship to child:

18a. (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