IN THE CIRCUIT COURT FOR [ ] COUNTY, MARYLAND Sitting as a Juvenile Court In the Matter of [ ] Department Of Social Services’ Petition for Guardianship With the Right to Consent to Adoption or Long Term Care Short of Adoption * * * * * * * Case Number(s): TERMINATION OF PARENTAL RIGHTS HEARING ORDER Having heard this matter on the issue of the [city/county] DSS petition for Guardianship and to terminate the rights of the parents in the above captioned matter and with the following persons present: Child _________________ Case Worker _____________ Mother _________________ Father __________________ Guardian _______________ CASA _________________ Child’s Attorney _________________ DSS Attorney __________________ Mother’s Attorney _______________ Father’s Attorney________________ Custodian _____________________ Other ________________________ by the Court for [county], on this_________ day of _______________ 200___, the Court finds: That [Name of Mother] and [Name of Father] knowingly, willingly and voluntarily relinquish their respective natural parental rights and responsibilities to the above captioned Respondent(s) [or First or Full Name of Child]. The Court’s efforts to ensure that the relinquishment was voluntary and informed are as follows: ; or That pursuant to the Family Law Article of the Maryland Annotated Code § 5-323, the Court finds by clear and convincing evidence that it is not in the best interest of the Respondent(s) to terminate the natural parental rights of [mother’s name] and [father’s name]. These findings are based on the following reasons: ; or That pursuant to §5-323 of the Family Law Article of the Maryland Annotated Code, the Court finds by clear and convincing evidence that it is in the best interest of the Respondent(s) to terminate the parental rights of [mother’s name] and [father’s name], and That the child was found to be a Child in Need of Assistance on the _____ day of __________, 200____, in the Circuit Court of [County] [State]. That the Court gave primary consideration to the health and safety of the child. Page 1 of 5 JO 27 – Revised 1 February 2006 American LegalNet, Inc. www.USCourtForms.com After considering all of the factors enumerated under §5-323 (d) of the Family Law Article of Maryland Annotated Code, the Court finds by clear and convincing evidence That services [were/were not] offered to the parent prior to placement of the child. These services included: Social service agreements between the parents and the [city/county] DSS were fulfilled in the following manner: That the mother [has /has not] been able to adjust her circumstances, condition or conduct to make it in the best interest of the child to return home. That the mother [has/has not] maintained regular contact with her child since: ___________________ That the mother [has/has not] maintained regular contact with: o The local department since ________________ o Her child’s caregiver [name of caregiver] since _______________ . That the mother [has/has not ] contributed to the care and maintenance of her child since: :_________________________ That the father [has/has not] been able to adjust his circumstances, conduct, or conditions to make it in the best interest of the child to return home. *** That the father [has / has not] maintained regular contact with his child since:_________________________ That the father [has / has not] maintained regular contact with: o The local department since ________________ o Her child’s caregiver [name of caregiver] since _______________ . That the father [has / has not] contributed to the care and maintenance of his child since :_________________________ That the ______mother____ father [has / does not have] a disability that renders the parent unable to care for the immediate and ongoing physical or psychological needs of the child for long periods of time. That additional services [would / would not] likely bring about a lasting parental adjustment so that the child could return home within an ascertainable time because That the _____mother _____ father____ [has abused / has neglected the child, or a minor]. That on admission to a hospital for the child’s delivery, the mother tested positive for a drug as evidenced by a positive toxicology test; or That the child tested positive for a drug as evidenced by a positive toxicology test; AND That the mother refused the level of drug treatment recommended by a qualified addiction specialist, by a physician or psychologist. IN ADDITION IF APPLICABLE, it is further found: Page 2 of 5 JO 27 – Revised 1 February 2006 American LegalNet, Inc. www.USCourtForms.com That the ______mother_____ father subjected the child to chronic abuse, chronic and life threatening neglect, sexual abuse, or torture. [Must describe the torture, abuse, or neglect, including extent of injuries]; or That the _____mother_____ father has been convicted of a crime of violence against ____a minor offspring of the parent ______ the child_____ or another parent of the child______ ; or That the ______mother_____ father has been convicted of aiding or abetting, conspiring, or soliciting to commit a crime of violence ; or The ______mother _____father involuntarily lost parental rights to [name of sibling] who is the brother/sister of [the above-captioned child’s name]; That because the _______mother______ father committed the above act, crime of violence, or involuntarily lost parental rights to[name of sibling], return of the child poses an unacceptable risk to the child’s future safety; or That although the ________ mother ______father committed the above act, crime of violence, or involuntarily lost parental rights to [Name of sibling], return of the child does not pose an unacceptable risk to the child’s future safety It is further found, That the child’s emotional ties with and feelings toward his/her mother are as follows: That the child’s emotional ties with and feelings toward his/her father are as follows: That the child’s emotional ties with and feelings toward his/her siblings are as follows: That the child’s emotional ties with and feelings toward [names of others who may affect the child’s best interests significantly] are as follows: That the child [has/has not] made a good adjustment to community, home, placement, and school. That the child’s emotional response and feelings toward termination of parental rights are as follows: That the likely impact of termination of parental rights is That the following efforts were made, following the placement of the child into foster care, to finalize the child’s permanency plan: ; and That the efforts made by the local department [were / were not] reasonable because In light of the above-stated factual findings, on this ________day of ____________200____, it is therefore, ORDERED, Page 3 of 5 JO 27 – Revised 1 February 2006 American LegalNet, Inc. www.USCourtForms.com That the [County] Department of Social Services’ Petition for Guardianship with the Right to Consent to Adoption or Long Term Care Short of Adoption [is / is not] granted. ***IF PETITION IS GRANTED*** That DSS is granted guardianship of the Respondent for [appropriate placement/placement with relatives/other]; and it is further ORDERED, That DSS/DHMH provide or make referrals for the following services: □ educational/academic □ vocational assessment □ individual counseling □ substance abuse evaluation □ substance abuse treatment □ psychological evaluation □ psychiatric evaluation □ medical evaluation □ Other That _____________________ continues to be/be awarded limited guardianship for the purpose of making routine medical, dental, educational, psychological and out of state travel decisions on behalf of the Respondent. That the individual’s CINA case is terminated. ***IF PETITION IS NOT GRANTED*** That the Respondent (s) [or First or Full Name of Child] [remains/is placed] in the custody of the [local agency/ parent / relative / other] pending further disposition before this Court on the above-captioned matter; That [Executive Director] of the [county][DSS/local agency] be awarded limited guardianship for the purpose of routine medical, dental, educational, psychological decision making on behalf of the respondent, and out of state travel purposes; That the Respondent(s) [or First or Full Name of Child] permanency plan is: □ Return to the parent(s) [only if petition is not granted] □ Placement with a relative for ○ Adoption ○ Guardianship □ Adoption by a nonrelative □ Guardianship by a nonrelative □ Another Planned Permanent Living Arrangement because the following compelling reasons exist making return home, adoption or guardianship not in the respondent(s)’s best interests: with implementation to be achieved by:___________________ . Page 4 of 5 JO 27 – Revised 1 February 2006 American LegalNet, Inc. www.USCourtForms.com That visitation between the Respondent (s) [or First or Full Name of Child] and ______________________________________ is to be □ liberal and unsupervised; or □ supervised as arranged by the [local agency or its designee] with a minimum of ___________________________________ ; or □ until,_______________________________ ; or □ as arranged between the parties; incorporating but not merging the visitation agreement dated ______________; That there be no contact between Respondent(s) [or First or Full Name of Child] and_________________________________; That the [local DSS/DHMH/other agency] submit bi-annual written progress reports to the Court and all parties no later than [specify first date] and [specify second date]; That a__________Guardianship Reviewor _________CINA Review Hearing be scheduled on the ________ day of _________200___, at ________a.m./p.m before the Court ALL PARTIES LISTED ABOVE AS PRESENT RECEIVED NOTICE OF THE FINDINGS ON THE RECORD AND UPON COMPLETION A COPY OF THIS ORDER WAS □ HANDED TO THEM □ SENT BY FIRST CLASS MAIL. A COPY OF THIS ORDER WILL BE MAILED TO THOSE PARTIES NOT PRESENT. SERVICE IS TO BE BY: □ First class mail □ □ □ □ Sheriff’s Service on ______________________ Certified Mail, Return Receipt Requested on______________________ Appropriate means when an address is supplied to the Court Further notice has been waived ____________________________________ JUDGE ____________________________________ Date Page 5 of 5 JO 27 – Revised 1 February 2006 American LegalNet, Inc. www.USCourtForms.com