1 Report of Dependent Educational Needs Pursuant to Welfare and Institutions Code Section 317, Subdivision (e) DEPENDENCY ATTORNEY NAME: OFFICE NAME: OFFICE ADDRESS: OFFICE TELEPHONE: OFFICE FAX: COURT TELEPHONE: SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES JUVENILE DIVISION IN THE MATTER OF: ) COURT DEPARTMENT: )) CHILD CASE NUMBER: )) NEXT COURT DATE: ) ) REPORT OF DEPENDENT EDUCATIONAL NEEDS ) PURSUANT TO WELFARE AND INSTITUTIONS ) CODE SECTION 317, SUBDIVISION (e) A DEPENDENT ) A preliminary investigation regarding the above-captioned child is complete and dependency counsel submits this report to the court pursuant to Welfare and Institutions Code Section 317(e) for a court determination as to whether further action should be commenced. If the court refers this matter to outside counsel, such counsel is advised to independently investigate the information contained in this report as it is based solely on documents and information available at this time. 1.DEPENDENT INFORMATIONA)NAME:B)DATE OF BIRTH:C)PRIMARY LANGUAGE:2.DEPENDENT CONTACT INFORMATIONA)CURRENT RESIDENCE OF CHILD:B)TELEPHONE NUMBER:C)CARETAKER222S NAME AND RELATIONSHIP TO CHILD:D)NAME AND STATUS OF EDUCATIONAL RIGHTS HOLDER: PARENT: LEGAL GUARDIAN: American LegalNet, Inc. www.FormsWorkFlow.com 2 Report of Dependent Educational Needs Pursuant to Welfare and Institutions Code Section 317, Subdivision (e) RESPONSIBLE ADULT (BY COURT227WIC 361): SURROGATE (BY SCHOOL227GOV. CODE 7579.5): ADDRESS: TELEPHONE NUMBER: PRIMARY LANGUAGE: E)NAME AND LOCATION OF CHILD222S CURRENT SCHOOL:F)NAME AND TELEPHONE NUMBER OF CHILD222S CSW AND CSW222S SUPERVISOR:G)NAME AND TELEPHONE NUMBER OF CHILD222S CASA:H)NAME AND TELEPHONE NUMBER OF DCFS EDUCATION LIAISON:3.PARTY INFORMATION (for noticing purposes)A)BENCH OFFICER NAME, COURTROOM ADDRESS & PHONE:B)MOTHER222S ATTORNEY NAME, ADDRESS AND TELEPHONE:C)FATHER222S ATTORNEY NAME, ADDRESS AND TELEPHONE:D)COUNTY COUNSEL NAME, ADDRESS, AND TELEPHONE:E)OTHER PARTY NAME, ADDRESS AND TELEPHONE:4.CHILD222S BACKGROUND INFORMATIONA)MOTHER222S NAME, ADDRESS AND TELEPHONE:B)FATHER222S NAME, ADDRESS AND TELEPHONE:C)IS CHILD A REGIONAL CENTER CLIENT? YES NO NAME OF REGIONAL CENTER: American LegalNet, Inc. www.FormsWorkFlow.com 3 Report of Dependent Educational Needs Pursuant to Welfare and Institutions Code Section 317, Subdivision (e) D)IS CHILD A SPECIAL EDUCATION STUDENT? YES NO REASON FOR CLASSIFICATION: DATE OF LAST IEP MEETING (ATTACH TO REFERRAL): DOES LAST IEP INCLUDE 223ERMHS224 (formerly AB3632) SERVICES? E)MENTAL HEALTH ISSUES:F)PREEXISTING MEDICAL CONDITIONS:5.REASON FOR REFERRAL FOR REPRESENTATIONA)TYPE OF ADVOCACY NEEDED: (check all that apply) SPECIAL EDUCATION: ELIGIBILITY SPECIAL EDUCATION: NON-COMPLIANCE SPECIAL EDUCATION: CHANGE OF PLACEMENT/SERVICES SPECIAL EDUCATION: ERMHS (formerly AB 3632) ENROLLMENT HARASSMENT/CIVIL RIGHTS POOR ACADEMIC PERFORMANCE TRANSFER EXPULSION OTHER (including Section 504 services) B)BRIEF DESCRIPTION OF ADVOCACY NEEDED:C)DEADLINE OR HEARING DATE BY WHICH ADVOCACY IS NEEDED:D)TYPE OF UPCOMING EDUCATION HEARING (IF ANY): IEP MEETING (INITIAL) IEP MEETING (REVIEW) MANIFESTATION DETERMINATION IEP PRE-EXPULSION MEETING EXPULSION HEARING 504 PLAN COMPLIANCE COMPLAINT American LegalNet, Inc. www.FormsWorkFlow.com 4 Report of Dependent Educational Needs Pursuant to Welfare and Institutions Code Section 317, Subdivision (e) DUE PROCESS OTHER E)DESCRIPTION OF ANY PRIOR HEARINGS OR ADVOCACY:6.ADDITIONAL INFORMATIONPLEASE IDENTIFY (AND ATTACH IF POSSIBLE) ANY SUPPORTING DOCUMENTATIONTHAT YOU EITHER POSSESS OR WHICH YOU KNOW EXISTS.This report is complete to the best of my knowledge at the time of filing. If I receive any further Information or documents prior to notification that an education attorney has accepted this case, I willfile them as a supplement to this report with the office of the Presiding Judge as soon as possible. Dated: Respectfully submitted, By: Dependency Court Attorney for Child American LegalNet, Inc. www.FormsWorkFlow.com