Superior Court of California, County of Sacramento Street Address: 3341 Power Inn Road Mailing Address: For Court Use Only 3341 Power Inn Road City and Zip Code: Branch Name: Sacramento, CA 95826 William R. Ridgeway Family Relations Courthouse Juvenile Dependency Court Name of Person to be Evaluated/Assessed: Case Number: Case Name: Department: Judge/Referee: Next Court Date: COURT ORDERED PSYCHOLOGICAL/PSYCHIATRIC EVALUATION OR MENTAL HEALTH ASSESSMENT – FOR CHILDREN Good cause appearing therefore, the Court hereby orders the Department of Health and Human Services to make the child available for the following evaluation(s) or assessment(s): 1. Urgent Psychiatric Assessment for Second Opinion Re: Administration of Psychotropic Medications. The Court has received a request to administer psychotropic medication to the child. The child is under the age of 8 years and/or multiple medications are requested. The Court requires guidance as to what medications are appropriate to this child with this child’s particular conditions. The DHHS shall refer the child within 5 court days of the issuance of this order to a child or adolescent psychiatrist. The DHHS is authorized to release to the selected mental health professional those DHHS and Dependency Court records necessary for the completion of the evaluation. The evaluation shall address all of the checked items below and the completed report provided to DHHS within 15 days. The DHHS shall report to the Court no later than 20 days the results of the evaluation. a. b. c. d. e. f. What is the child’s diagnosis? What are his/her treatment needs, including the appropriate medication regiment? Is the current medication regiment meeting the child’s needs? If not, what do you recommend? What other therapeutic services do you recommend for the child? Does the child pose a danger to self or others or is the child in need of intensive hospital-based treatment? Is the child in need of intensive hospital-based treatment? Form JC-E\327 Adopted for Mandatory Use Effective: 02/05/2007 COURT ORDERED PSYCHOLOGICAL/PSYCHIATRIC EVALUATION OR MENTAL HEALTH ASSESSMENT FOR CHILDREN Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com g. h. i. 2. If the child is not in need of intensive hospital-based treatment, what types of community-based treatment is recommended? Comment on the treatment types (psychotherapy, pharmacotherapy, etc.), frequency of appointments, supervisory needs (i.e., need supervision after school, 24 hours/day, 1:1 supervision, 2:1 supervision, etc.) or other psychosocial needs. Does the child need psychological testing1? Other, specify: Mental Health Assessment and Treatment Planning for the Child The Child appears to have a mental illness and requires a mental health assessment to assist the Court in determining an appropriate disposition, or permanent plan. The DHHS shall refer the child within 15 court days of the issuance of this order to a mental health clinician. The DHHS is authorized to release to the selected mental health professional those DHHS and Dependency Court records necessary for the completion of the evaluation/assessment. The assessment shall address all of the checked items below. The mental health clinician shall provide a written report to the DHHS within 45 days. DHHS shall report to the Court no later than 60 days the results of the assessment. a. b. c. d. e. f. g. h. i. j. What is the child’s diagnosis and what are his/her treatment needs? What type of home environment will best meet the child’s needs? What type(s) of treatment is recommended for the child? Is the child in need of further psychological or psychiatric evaluation? If so, what type? Does the child meet criteria for ACESS psychological evaluation? If so, clinician shall make the referral expeditiously and inform DHHS the referral is complete. Is the care provider or parent in need of any specialized services or training to assist in the care of the child? Is the child in need of intensive hospital-based treatment? If the child is not in need of intensive hospital-based treatment, what types of community-based treatment is recommended? Comment on the treatment types (psychotherapy, pharmacotherapy, etc.), frequency of appointments, supervisory needs (i.e., need supervision after school, 24 hours/day, 1:1 supervision, 2:1 supervision, etc.) or other psychosocial needs. Does the child need psychological testing2? Other, specify: 1 The CAPS clinic will not withhold medication for the evaluation and will automatically make the referral through the ACESS process in conjunction with the DHHS social worker. 2 The evaluator/assessor provider will commence treatment pending the evaluation and will automatically make the referral through the ACCESS process in conjunction with the DHHS social worker. Form JC-E\327 Adopted for Mandatory Use Effective: 02/05/2007 COURT ORDERED PSYCHOLOGICAL/PSYCHIATRIC EVALUATION OR MENTAL HEALTH ASSESSMENT FOR CHILDREN Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com 3. Assessment of the Benefit to the Child of Continuing the Relationship with the Sibling. WIC § 366.26 (c (1) (E). 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 substantially interfere with a child’s sibling relationship. The DHHS is authorized to release to the selected mental health professional those DHHS and Dependency Court records necessary for the completion of the evaluation/assessment. The assessment is only in regard to the effect on this child’s relationship with his/her siblings and not in regard to the sibling’s relationship with this child. The assessment shall address all of the checked items below. The assessor shall provide a written report to the DHHS within 45 days. DHHS shall report to the court no later than 60 days the results of the assessment. a. b. c. d. e. Does a significant sibling relationship exist? Describe the sibling relationship, including whether the siblings were raised together in the same home or if they shared significant common experiences. How frequently is the child seeing the siblings and what do the visits consist of (length, activities, and role)? In your opinion, is ongoing contact in the child’s best interests, including the child’s long term emotional interest as compared to the benefit of legal permanence through adoption? Is there a strong, close bond with the sibling? Other, specify: Date: Judge/Referee of the Juvenile Court Original to Court File Copy to DHHS Court Officer Copy to DHHS Copies to counsel for child(ren) and parent(s) Form JC-E\327 Adopted for Mandatory Use Effective: 02/05/2007 COURT ORDERED PSYCHOLOGICAL/PSYCHIATRIC EVALUATION OR MENTAL HEALTH ASSESSMENT FOR CHILDREN Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com