The child or nonminor is placed or will be placed in a county that is not the county of original jurisdiction (home county). The out-of-county placement is in (name county): county.A request was made to the agency making this placement that the responsibility for providing specialty mental health services to the child or nonminor shoud be waived and not transferred to the new county. That request was made on (date) by (name): . Request for Hearing on Waiver of Presumptive TransferJV-214, Page 1 of 2Judicial Council of California, www.courts.ca.gov New September 1, 2018, Mandatory Form JV-214Request for Hearing on Waiver ofPresumptive Transfer Clerk stamps date here when form is filed. Fill in court name and street address: Superior Court of California, County of Court fills in case number when form is filed.Case Number: Fill in child's name and date of birth:3 2Use this form to request a court hearing to challenge the decision made by the placing agency on the request for waiver of presumptive transfer of the responsibility for specialty mental health services. (Read form JV-214-INFO, Instructions for Requesting a Hearing to Review Waiver of Presumptive Transfer of Specialty Mental Health Services).1 My relationship to the child or nonminor:a.b. Self Person or agency responsible for making mental health decisions on behalf of the child or nonminorc. The child222s or nonminor222s attorneyd. Parent or legal guardiane. Other:My contact information (if confidential, use form JV-287):a.b.c.d.e. Name: Street address: Telephone number: E-mail address: 4On (date):, the agency making the placement informed me:a. b. That an exception or waiver applies to the rule that the responsibility for providing specialty mental health services be transferred to the county where the child or nonminor lives or will live, and the responsibility should remain with the child222s or nonminor222s home county. That the request for the waiver of the responsibility for the child222s or nonminor222s specialty mental health services is denied and the responsibility for those services should be transferred to the new county of residence. 5I disagree with the agency222s decision about transferring the responsibility for specialty mental health services to the new county, as follows:a. The responsibility for the child222s or nonminor222s specialty mental health services should transfer to the countywhere the child or nonminor lives or will live. 6 American LegalNet, Inc. 6 JV-214, Page 2 of 2New September 1, 2018Request for Hearing on Waiver of Presumptive Transfer Sign your name Date: Type or print your name Case Number: Child's/Nonminor's Name:b.(1) The transfer would disrupt continuity of care or delay access to services provided to the child or nonminor.(2) The transfer would interfere with family reunification efforts documented in the individual case plan.(3) The child222s or nonminor222s placement in a county other than the county of original jurisdiction is expected to last less than six months.(4) The child222s or nonminor222s residence is within 30 minutes of travel time to his or her established specialty mental health care provider in the county of original jurisdiction. The following exception to presumptive transfer should be applied and the responsibility for providing or arranging specialty mental health services should remain with the child222s or nonminor222s home county:My request in 6 is in the child222s or nonminor222s best interests because (explain the best interest to the child or nonminor and provide a brief factual description of the exception to presumptive transfer selected in item 6b): 7 I am requesting that the court grant a hearing on this matter. 8On (date): I informed the placing agency that I was requesting a court hearing to review the decision on presumptive transfer by providing the placing agency with a copy of this form. 9 American LegalNet, Inc.