Form JV-225 "Your Child's Health and Education" - California

What Is Form JV-225?

This is a legal form that was released by the California Superior Court - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the California Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form JV-225 by clicking the link below or browse more documents and templates provided by the California Superior Court.

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Download Form JV-225 "Your Child's Health and Education" - California

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Clerk stamps date here when form is filed.
JV-225
Your Child's Health and Education
To the social worker or probation officer: If the parent or guardian needs
help completing this form, please help him or her.
To the parent or guardian: Complete and sign this form. If you need more
space to answer, attach one or more sheets of paper to this form and write
“JV-225” at the top of each page. The information requested on this form is
necessary to meet the medical, dental, mental health, educational, and
developmental needs of your child. The court has directed you to provide
your child’s medical, dental, mental health, educational, and developmental
Fill in court name and street address:
information. The court has also directed you to provide your medical, dental,
Superior Court of California, County of
mental health, and educational information and, if you know, the same
information about the other parent or guardian. If you need help, the social
worker or probation officer will help you fill out this form.
Your name:
1
Your relationship to child:
Your home address:
Clerk fills in case number when form is filed.
City:
State:
Zip code:
Case Number:
Your mailing address:
City:
State:
Zip code:
Your telephone number:
2
Your child’s name:
a. Your child’s date of birth:
Hospital:
c.
Where was your child born?
b.
d.
Your child’s birth weight:
City:
State:
Country:
Child’s Health
Yes
No
3
Does your child have any physical or mental health challenges?
If yes, is your child receiving any assistance, services, or treatment for these problems? (Explain):
a.
Allergies:
b.
Injuries:
c.
Diseases:
d.
Disabilities:
e.
Other:
f.
Other:
Has your child ever been admitted to the hospital for care or treatment of any of the conditions in item
?
4
3
Yes
No
If yes, please explain:
Is your child taking any medication?
Yes
No
5
If yes, please list each medication and explain why your child is taking it:
Medication and dosage
Reason for taking medication
Date begun
Judicial Council of California, www.courts.ca.gov
JV-225,
Your Child's Health and Education
Page 1 of 5
Revised January 1, 2014, Mandatory Form
Welfare and Institutions Code, § 16010
Clerk stamps date here when form is filed.
JV-225
Your Child's Health and Education
To the social worker or probation officer: If the parent or guardian needs
help completing this form, please help him or her.
To the parent or guardian: Complete and sign this form. If you need more
space to answer, attach one or more sheets of paper to this form and write
“JV-225” at the top of each page. The information requested on this form is
necessary to meet the medical, dental, mental health, educational, and
developmental needs of your child. The court has directed you to provide
your child’s medical, dental, mental health, educational, and developmental
Fill in court name and street address:
information. The court has also directed you to provide your medical, dental,
Superior Court of California, County of
mental health, and educational information and, if you know, the same
information about the other parent or guardian. If you need help, the social
worker or probation officer will help you fill out this form.
Your name:
1
Your relationship to child:
Your home address:
Clerk fills in case number when form is filed.
City:
State:
Zip code:
Case Number:
Your mailing address:
City:
State:
Zip code:
Your telephone number:
2
Your child’s name:
a. Your child’s date of birth:
Hospital:
c.
Where was your child born?
b.
d.
Your child’s birth weight:
City:
State:
Country:
Child’s Health
Yes
No
3
Does your child have any physical or mental health challenges?
If yes, is your child receiving any assistance, services, or treatment for these problems? (Explain):
a.
Allergies:
b.
Injuries:
c.
Diseases:
d.
Disabilities:
e.
Other:
f.
Other:
Has your child ever been admitted to the hospital for care or treatment of any of the conditions in item
?
4
3
Yes
No
If yes, please explain:
Is your child taking any medication?
Yes
No
5
If yes, please list each medication and explain why your child is taking it:
Medication and dosage
Reason for taking medication
Date begun
Judicial Council of California, www.courts.ca.gov
JV-225,
Your Child's Health and Education
Page 1 of 5
Revised January 1, 2014, Mandatory Form
Welfare and Institutions Code, § 16010
Case Number:
Child’s name:
When was your child last seen by a doctor?
6
Date:
Doctor’s name:
Office address:
Mailing address (if different):
Telephone number:
When was your child last seen by a dentist?
7
Date:
Dentist’s name:
Office address:
Mailing address (if different):
Telephone number:
List the names of all doctors, nurses, dentists, hospitals, clinics, and other health-care providers and healers,
8
other than those listed in 6 and 7, who have seen your child within the past two years:
Address (city, state, zip code)
Date of last visit
Reason for visit
Name
What doctor, nurse, dentist, hospital, clinic, or other health-care provider has health records regarding your child?
9
a.
Medical records:
b.
Dental records:
Mental health records:
c.
d. Other:
When was your child’s eyesight last tested?
10
Date of examination:
Who examined your child’s sight?
Address (include city, state, zip code):
Telephone number:
Yes
No
Does your child wear glasses or contact lenses?
11
Yes
No
12
Does your child wear a hearing aid?
Is your child covered by an insurance policy?
13
Yes
No
a. Medical
(If yes, specify insurance policy):
b. Dental
Yes
No
(If yes, specify insurance policy):
c. Vision
Yes
No
(If yes, specify insurance policy):
Child’s Education
When your child was living with you, what school did your child attend?
14
Name of school:
Address (include city, state, zip code):
Is your child still allowed and able to attend this school?
a.
Yes
No
b.
If no, did you agree to give up your child’s right to remain at this school?
Yes
No
Your Child's Health and Education
JV-225,
Revised January 1, 2014
Page 2 of 5
Case Number:
Child’s name:
c.
When your child was living with you, was your child receiving, or had your child received, any assistance
14
or help at school or any assessments, evaluations, services, or accommodations to help your child with any
physical, mental, or learning-related disabilities or other special educational needs?
Yes
No
(1)
If yes, what assessments, evaluations, services, or accommodations was your child receiving?
(2)
Who gave your child these educational or developmental services?
Yes
No
d.
Has your child ever been referred to a regional center for developmental services?
If yes, list the name and location of the regional center and the date of the referral.
e.
If applicable, do you have a copy of your child’s individualized education program (IEP), section 504 plan,
individualized family service plan (IFSP), individual program plan (IPP), or quality assurance assessment?
Yes
No
f.
What language did your child first learn to speak?
g.
What is his or her primary language?
h.
What language do you most often use when speaking to your child?
i.
Has your child ever been identified as limited English proficient or as an English Language Learner by a school?
Yes
No
j.
Yes
No
Has your child ever been enrolled in a specialized program to learn English?
List all other schools or day care facilities your child has attended:
15
School (name, city, state):
Dates of attendance:
Dates of attendance:
School (name, city, state):
School (name, city, state):
Dates of attendance:
School (name, city, state):
Dates of attendance:
a.
What grade is your child in?
16
b.
Does he or she have any special needs?
Yes
No
If yes, please describe:
c.
If your child is three years old or younger, do you believe that your child might have motor, developmental,
Yes
No
or other delays?
If yes, explain why:
What assessments, evaluations, services, treatment, or accommodations do you believe your child needs for the
delay?
Your Child's Health and Education
JV-225,
Revised January 1, 2014
Page 3 of 5
Case Number:
Child’s name:
d.
16
Do you believe your child might have a disability?
Yes
No
If yes, please describe:
What assessments, evaluations, services, treatment, or accommodations do you believe your child needs for the
disability?
Yes
No
a.
Has your right to make educational decisions for your child been limited?
17
If yes, who has the right to make educational decisions for your child?
Name:
Relationship to child:
Yes
No
b.
Has your right to make developmental-services decisions for your child been limited?
same as 17a.
If yes, who has the right to make developmental-services decisions for your child?
Name:
Relationship to child:
Biological Parent’s Health and Education
(State law requires you to provide this information about yourself. If
you do not want to provide this information, please talk to your attorney.)
a.
When were you last seen by a doctor and dentist?
18
(1)
What medical problems run in your family?
(2)
Do you have medical problems or disabilities?
Yes
No
If yes, please describe:
(3)
What medications do you take?
Medication
Reason for taking medications
b.
What is your educational history?
(1) School last attended (name, city, state):
(2) Last grade completed:
a.
If you know, provide the following information about your child’s other biological parent:
19
(1) Name of other parent:
Your Child's Health and Education
JV-225,
Revised January 1, 2014
Page 4 of 5
Case Number:
Child’s name:
a.
(2)
Other parent’s medical problems and disabilities
19
(Please include physical, mental, developmental, and learning problems):
(3)
My child’s other parent takes the following medications:
Medication
Reason for taking medication
(4) The following medical problems run in the family of my child’s other parent:
b.
My child’s other parent has the following educational history:
(1) School last attended:
(2) Last grade completed:
I declare that the information on this form is true and correct to the best of my knowledge.
Date:
}
Parent/guardian signs here
Type or print parent’s/guardian’s name
Date:
}
Social worker signs here
Type or print social worker’s name
Date:
}
Type or print probation officer’s name
Probation officer signs here
JV-225,
Your Child's Health and Education
Revised January 1, 2014
Page 5 of 5
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