JV-225 Your Child's Health and Education Clerk stamps date here when form is filed. To the social worker or probation officer: If the parent or guardian needs help completing this form, please help him or her. To the parent or guardian: Complete and sign this form. If you need more space to answer, attach one or more sheets of paper to this form and write "JV-225" at the top of each page. The information requested on this form is necessary to meet the medical, dental, mental health, educational, and developmental needs of your child. The court has directed you to provide your child's medical, dental, mental health, educational, and developmental information. The court has also directed you to provide your medical, dental, mental health, and educational information and, if you know, the same information about the other parent or guardian. If you need help, the social worker or probation officer will help you fill out this form. 1 Your name: Your relationship to child: Your home address: City: Your mailing address: City: Your telephone number: Fill in court name and street address: Superior Court of California, County of Clerk fills in case number when form is filed. State: State: Zip code: Zip code: Case Number: 2 Your child's name: a. Your child's date of birth: b. Where was your child born? City: State: c. Hospital: d. Your child's birth weight: Country: Child's Health 3 Yes No Does your child have any physical or mental health challenges? If yes, is your child receiving any assistance, services, or treatment for these problems? (Explain): a. Allergies: b. Injuries: c. Diseases: d. Disabilities: e. Other: f. Other: Has your child ever been admitted to the hospital for care or treatment of any of the conditions in item 3 ? Yes No If yes, please explain: 4 5 Is your child taking any medication? Yes No If yes, please list each medication and explain why your child is taking it: Medication and dosage Reason for taking medication Date begun Judicial Council of California, www.courts.ca.gov Revised January 1, 2014, Mandatory Form Welfare and Institutions Code, § 16010 Your Child's Health and Education JV-225, Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Child's name: 6 When was your child last seen by a doctor? Date: Doctor's name: Office address: Mailing address (if different): Telephone number: When was your child last seen by a dentist? Date: Dentist's name: Office address: Mailing address (if different): Telephone number: List the names of all doctors, nurses, dentists, hospitals, clinics, and other health-care providers and healers, other than those listed in 6 and 7, who have seen your child within the past two years: Date of last visit Reason for visit Address (city, state, zip code) Name 7 8 9 What doctor, nurse, dentist, hospital, clinic, or other health-care provider has health records regarding your child? a. Medical records: b. Dental records: c. Mental health records: d. Other: 10 When was your child's eyesight last tested? Date of examination: Who examined your child's sight? Address (include city, state, zip code): Telephone number: 11 12 13 Does your child wear glasses or contact lenses? Does your child wear a hearing aid? Yes Yes No No Is your child covered by an insurance policy? Yes No a. Medical (If yes, specify insurance policy): Yes No (If yes, specify insurance policy): b. Dental Yes No (If yes, specify insurance policy): c. Vision Child's Education 14 When your child was living with you, what school did your child attend? Name of school: Address (include city, state, zip code): Yes No a. Is your child still allowed and able to attend this school? b. If no, did you agree to give up your child's right to remain at this school? Yes No JV-225, Page 2 of 5 Revised January 1, 2014 Your Child's Health and Education Case Number: Child's name: 14 c. When your child was living with you, 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 or developmental services? d. Has your child ever been referred to a regional center for developmental services? If yes, list the name and location of the regional center and the date of the referral. Yes No e. If applicable, do you have a copy of your child's individualized education program (IEP), section 504 plan, individualized family service plan (IFSP), individual program plan (IPP), or quality assurance assessment? Yes No f. What language did your child first learn to speak? g. What is his or her primary language? h. What language do you most often use when speaking to your child? i. Has your child ever been identified as limited English proficient or as an English Language Learner by a school? Yes No j. Has your child ever been enrolled in a specialized program to learn English? 15 Yes No List all other schools or day care facilities your child has attended: School (name, city, state): School (name, city, state): School (name, city, state): School (name, city, state): Dates of attendance: Dates of attendance: Dates of attendance: Dates of attendance: 16 a. What grade is your child in? b. Does he or she have any special needs? If yes, please describe: Yes No c. If your child is three years old or younger, do you believe that your child might have motor, developmental, Yes No or other delays? If yes, explain why: What assessments, evaluations, services, treatment, or accommodations do you believe your child needs for the delay? Revised January 1, 2014 Your Child's Health and Education JV-225, Page 3 of 5 Case Number: Child's name: 16 d. Do you believe your child might have a disability? If yes, please describe: Yes No What assessments, evaluations, services, treatment, or accommodations do you believe your child needs for the disability? 17 a. Has your right to make educational decisions for your child been limited? If yes, who has the right to make educational decisions for your child? Name: Relationship to child: Yes No b. Has your right to make developmental-services decisions for your child been limited? If yes, who has the right to make developmental-services decisions for your child? Name: Relationship to child: Yes No same as 17a. Biological Pa