Form JC - E - 326 Adopted for Mandatory Use Effective: 02/05/2007 Revi se d: 05/18/2018 COURT ORDERED PSYCH O LOGIC A L/PSYCH I A T RIC EVALUATION OR MENTAL HEALTH ASS ESSMENT FOR P A RENT(S) Page 1 of 3 Superior Court of California, County of Sacramento Street Address: 3341 Power Inn Road Mailing Address: 3341 Power Inn Road City and Zip Code: Sacramento, CA 95826 Branch Name: William R. Ridgeway Family Relations Courthouse, Juvenile Dependency Court For Court Use Only Name of Person to be Evaluated/Assessed: Case N u mber: Case Name: Department: Jud g e/Refe r e e : N e xt Court Da t e: COURT ORDERED PSYCHO L OGICAL/PSYCHIATRIC EVALUATION OR MENTAL HEAL T H AS S ES S MENT 226 FOR PAR E NT(S) Good cause appearing therefore, the Court hereby orders the Department of Child, Family and Adult Services to arrange for the following evaluation(s) or assessment(s) and make the child available for same: 1. Psychological/Psychiatric Evaluation Prior to Disposition to Determine if the Parent Can Utilize Services pursuant to Welfare & Institutions Code (WIC) 247 361.5(b) (2). The parent appears to suffer from a mental disability that may render him/her incapable of utilizing available services designed to assist the parent to safely parent the child. The Department of Child, Family and Adult Services (DCFAS) is authorized to release to the selected professional those DHHS and Dependency Court records necessary for the completion of the assessment. The evaluation(s) shall address all of the checked items below and the completed report(s) provided to the DCFAS within 45 days. DCFAS shall report to the Court the results of the evaluation(s) no later than 60 days from this order. The Court orders DCFAS to arrange:1 or 2 Psychological/psychiatric evaluations1 a. Is the parent suffering from a mental disability? If so, what is the parent222s disability or diagnosis? b. Can the parent utilize available services designed to help the parent gain the skills necessary to parent a child. This parent has: 6 months to demonstrate they have made substantive progress in their case plan. Is this feasible for this client, given their disability? OR c. Can the parent utilize available services designed to help the parent gain the skills necessary to parent a child. This parent has: 12 months to demonstrate they have utilized the services such that substantial risk of abuse or neglect no longer prevents the child from returning to the parent. Is this feasible for this client, given their disability? 1 The Section references Family Code Section 7820 which requires evidence from (2) experts. American LegalNet, Inc. www.FormsWorkFlow.com Form JC - E - 326 Adopted for Mandatory Use Effective: 02/05/2007 Revi se d: 05/18/2018 COURT ORDERED PSYCH O LOGIC A L/PSYCH I A T RIC EVALUATION OR MENTAL HEALTH ASS ESSMENT FOR P A RENT(S) Page 2 of 3 d. If the parent can utilize available services, describe the types of treatment, interventions and services, including any recommendations as to the manner in which the services or treatment should be delivered to best help the parent to utilize available services designed to assist the parent to safely parent a child. e. Other, specify: 2. Mental Health Assessment to Insure Reunification Services are Tailored to the Parent222s Needs. The parent suffers from a mental health disability that appears to hinder his/her ability to parent the child safely. A mental health assessment is required to assist the Court in determining what available services will best assist the parent in developing the skills necessary to safely parent the child. The DCFAS is authorized to release to the selected mental health professional those DCFAS and Dependency Court records necessary for the completion of the assessment. The assessment shall address all of the checked items below. The mental health professional shall provide a written report to the DCFAS within 45 days. DCFAS shall report to the Court no later than 60 days. a. What if any, is the parent222s diagnosis? b. What specific social, mental health or other available services will assist the parent to develop the skills necessary to parent the child? c. Describe any particular techniques that should be utilized or avoided to be effective in assisting the parent to gain the skills necessary to parent the child? d. Based on your assessment, please describe techniques or services that should not be utilized as they would be ineffective in assisting the parent to gain the skills necessary to parent the child. e. Does the parent have a developmental disability? f. Is psychological testing or a psychiatric evaluation needed to answer questions a-e? g. Other, specify: 3. Psychological Evaluation Following a Mental Health Assessment to Insure Reunification Services are Tailored to the Parent222s Needs. The parent suffers from a mental health disability that appears to hinder his/her ability to parent the child safely. A psychological evaluation and testing is required to assist the Court in determining what services will best assist the parent in developing the skills necessary to safely parent the child. The DCFAS is authorized to release to the selected mental health professional those DCFAS and dependency Court records necessary for the completion of the evaluation. The evaluation shall address all of the checked items below. The evaluator shall provide a written report to the DCFAS within 45 days. DCFAS shall report to the Court no later than 60 days the results of the evaluation and include the recommendations for a specifically tailored case plan. a. What if any, is the parent222s diagnosis? b. What specific social, mental health, parenting or other available services will assist the parent to develop the skills necessary to parent the child? c. Describe any particular techniques that should be utilized or avoided to be effective in assisting the parent to gain the skills necessary to parent the child? d. Does the parent have a developmental disability? e. Other, specify: American LegalNet, Inc. www.FormsWorkFlow.com Form JC - E - 326 Adopted for Mandatory Use Effective: 02/05/2007 Revi se d: 05/18/2018 COURT ORDERED PSYCH O LOGIC A L/PSYCH I A T RIC EVALUATION OR MENTAL HEALTH ASS ESSMENT FOR P A RENT(S) Page 3 of 3 4. Assessment of the Benefit to the Child of Continuing the Relationship with the Parent. WIC 247 366.26(c) (1) (A). The Court set a hearing to implement a permanent plan for the child. The most preferred permanent plan is adoption and termination of parental rights, unless termination of parental rights would be detrimental to the child because the mother/father has maintained regular visitation with the child and that mother/father relationship is such that the benefit in continuing that parent/child relationship is such that it would outweigh the benefit to the child of adoption. The DCFAS is authorized to release to the selected mental health professional those DCFAS and Dependency Court records necessary for the completion of the evaluation. The assessment shall address all of the checked items below. The assessor shall provide a written report to the DCFAS within 45 days. DCFAS shall report to the court no later than 60 days the results of the assessment. a. Does a significant parent/child relationship exist? Describe the parent/child relationship. b. How frequently is the child seeing the mother/father and what do the visits consist of (length, activities, and role)? c. In your opinion, would the child receive such a benefit from a continued relationship with the parent that it would outweigh the benefit the child would receive in an adoptive home with adoptive parents? d. Is the relationship between the parent and child sufficiently strong that the child would suffer from its termination? e. Other, specify: Date: f Judge/Referee of the Juvenile Court 203 Original to Court File 203 Copy to DCFAS Court Officer 203 Copy to DCFAS 203 Copies to counsel for child(ren) and parent(s) American LegalNet, Inc. www.FormsWorkFlow.com