JC-E-311 Mandatory JC-E-311 Adopted: 01/01/19 NOTICE OF PSYCHIATRIC HOSPITALIZATION AND/OR RELEASE OF MINOR Page 1 of 1 Application submitted by (Name and Address) Name: Street Address: City, State: Telephone Number: FOR COURT USE ONLY S U PE RI O R COU RT O F C A LIFO R NIA , C OU N T Y O F SAC R A M E N TO Street Address: 3341 Power Inn Road City and Zip Code: Sacramento CA 95826 Bra n ch Na m e: SITTING A S THE J UV E N I LE C O URT NAME OF CHILD/MINOR: NOTICE OF PSYCHIATRIC HOSPITALIZATION AND/OR RELEASE OF MINOR CASE NUMBER: 1. DCFAS has received notice that the child has been placed on the following hold: 72 hour psychiatric hold (WIC 247247 5150, 5585) on . 14 day psychiatric hold (WIC 247 5250) on . 30 day psychiatric hold (WIC 247 5270.15) on . Facility Name: Treating Professional: Address: Phone No.: Results of Certification/Evaluation attached. 2. The child has been released from hospitalization and is now placed as follows: Name: Address: Phone No.: Relationship: Confidential Placement Print or Type Name DCFAS Representative222s Signature Date American LegalNet, Inc. www.FormsWorkFlow.com