SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES JUVENILE COURT In the Matter of: Child COORDINATED HEALTH SERVICES REFERRAL AND ORDER Case No.: Department: Pursuant to this order, the Coordinated Health Services team (CHST) is requested to coordinate and assist with required medical/mental health services for: Name of C hild: Date of Birth: Referral Information: CSW n ame: Region: Telephone: Caregiver Name: Telephone: Brief description of medical/mental health concern: Medical/mental health service(s) requested: Child222s attorney222s name: Telephone: Identify attachments, if any: URGENT/EMERGENT. Checking this box necessitates both of the following: a)The Judicial Officer will be contacted directly, day or night, by the court pediatrician as soon as possible (withineighteen hours) at this court email . b)This signed referral form will be emailed to BOTH court pediatricians with high priority: Email to cnicholson@ph.lacounty.gov AND ebloch@ph.lacounty.gov Next court date: Date: Judge/Commissioner/Referee American LegalNet, Inc. www.FormsWorkFlow.com