State of Minnesota District CourtCounty Judicial District: Court File Number: Case Type: Parental Notification In the Matter of the Petition of: Report of the Guardian Ad Litem or Petitioner Date of Birth: I. MEDICAL INFORMATION 1. Has the Petitioner been examined by a physician? Yes No Date: 2. Have the abortion procedures and the medical risks been explained? Yes No 3. Have the aftercare procedures been explained and understood? Yes No 4. Has the Petitioner been informed and does Petitioner understand what to do if medical complications occur? Yes No 5. Has the Petitioner given a true statement of her medical history to the physician? Yes No 6. Did Petitioner222s physician advise her of any additional risks to her Yes No health as a result of her medical history? 7. Has the Petitioner given informed consent to the abortion? Yes No II. COUNSELING INFORMATION 1. Has Petitioner received counseling regarding having an abortion? Yes No If yes, name and agency of counselor; 2. Has Petitioner received counseling as to pregnancy alternatives? a. abortion Yes No b. adoption Yes No JUV202 State ENG Rev 01/02-D www.courts.state.mn.us/forms Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com c. marriage Yes No d. single parenthood Yes No 3. Does Petitoner feel she needs more counseling as to her decision to a. have an abortion? Yes No 4. Has Petitioner been counseled as to possible emotional and psychological a. Problems she may experience after the abortion? Yes No 5. Has Petitioner been counseled as to the methods of contraception that a. are available? Yes No III. PERSONAL INFORMATION 1. Does Petitioner wish to have an abortion? Yes No 2. Has Petitioner been coerced by any other party as to this decision? Yes No 3. Petitioner elects not to notify her parent(s) because: 4. Does Petitioner live with her parents? Yes No 5. What is Petitioner222s source of financial income? 6. Is Petitioner attending school? Grade Yes No 7. What is the highest school grade level Petitioner has completed? 8. Is Petitioner employed? Yes No 9. Place of employment: Address Job title: 10. What are Petitioner222s plans for the future (schooling, employment, etc.)? JUV202 State ENG Rev 01/02-D www.courts.state.mn.us/forms Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 11. State any additional information Petitioner wishes to bring to the court222s attention relative to the proposed abortion: Dated: Guardian Ad Litem on behalf of Petition or Petitioner Relationship to Minor JUV202 State ENG Rev 01/02-D www.courts.state.mn.us/forms Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com IV. RECOMMENDATION OF THE GUARDIAN AD LITEM A. Authorization to the physician without parental notification is recommended because: B. The minor is mature and capable of giving an informed consent, as evidenced by: C. The minor is not mature, but the proposed waiver of parental notification is in her best interests because: D. It is not recommended that authorization be granted because: Dated: Guardian Ad Litem JUV202 State ENG Rev 01/02-D www.courts.state.mn.us/forms Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com