SDSC JUV-255 (New 1/15) PETITION FOR MEDICAL, MENTAL HEALTH, Page 1 of 2 Mandatory Form DENTAL, AND/OR OTHER REMEDIAL CARE ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO.(Optional): EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST., SAN DIEGO, CA 92101 CENTRAL DIVISION, COUNTY COURTHOUSE, 220 W. BROADWAY, SAN DIEGO, CA 92101 CENTRAL DIVISION, JUVENILE COURT, 2851 MEADOW LARK DR., SAN DIEGO, CA 92123 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020 NORTH COUNTY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 CASE NUMBER (If app licable) IN THE MATTER OF CHILD222S DATE OF BIRTH DSS CASE NUMBER PETITION FOR MEDICAL, MENTAL HEALTH, DENTAL, AND/OR OTHER REMEDIAL CARE CC CASE NUMBER ( If ap plicable) Mother222s Name: Father222s Name: Legal Guardian222s Name: Petition in support of authorization for: Medical care Mental health care Dental care Other remedial care FOUNDATIONAL INFORMATION Petitioner, , declares as follows: (Print name) PETITIONER222S PROFESSIONAL QUALIFICATIONS I have been informed by that the above-referenced child is in need of an examination and/or treatment Unable to reach parent/guardian to obtain consent. The Agency and/or the health care provider has been unable to make contact with the child's parent, guardian, or person standing in loco parentis, despite the following efforts to provide notice of the recommended medical, mental health, dental and/or other remedial care to the parent, guardian, or person standing in loco parentis for the above-referenced child ( Attempted in-person contact with (name) on (date) at (time) at (location) . American LegalNet, Inc. www.FormsWorkFlow.com SDSC JUV-255 (New 1/15) PETITION FOR MEDICAL, MENTAL HEALTH, Page 2 of 2 Mandatory Form DENTAL, AND/OR OTHER REMEDIAL CARE CHILD222S NAME CASE NUMBER Contact has been attempted for all known telephone numbers and email addresses with the following result (identify each telephone number, email address, date/time, and if a message was left or not): Written notice has been left at the last known address for the above-referenced child (identify address, date, time): Other (describe attempts with date, time): Parent/Guardian has objected to care, necessitating an order of the court. The parent, guardian, or person standing in loco parentis for the above-referenced child has been advised of the time and place of the proposed care and of the right to be present. The parent, guardian, or person standing in loco parentis has objected to the recommended medical, mental health, dental, and/or other remedial care, and communicated the following objection(s) to the proposed care (state the parent/guardian's reason(s), if any, on the following lines): REQUEST FOR AN ORDER OF THE COURT The above-referenced child was taken into temporary custody on and is in need of medical, mental health, dental, and/or other remedial care as explained in and in the time frame stated in the attached Declaration of Licensed Health Care Provider in Support of Order for Examination and Treatment of a Child in the Custody of the County of San Diego. Furthermore, there is no parent, guardian, or person standing in loco parentis available to, capable of, or willing to authorize medical, mental health, dental, and/or other remedial care for the child. Therefore, pursuant to Welf. & Inst. Code 247 369, the Agency requests that the court authorize the recommended medical, mental health, dental, and/or other remedial care be administered as indicated in the attached Declaration of Licensed Health Care Provider in Support of Order for Examination and Treatment of a Child in the Custody of the County of San Diego. VERIFICATION I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct. Date: at (city, state): Type or print name Signature of Petitioner/Social Worker Petitioner222s/Social Worker222s telephone number: American LegalNet, Inc. www.FormsWorkFlow.com