Form AD512NMD "Psychosocial and Medical History of Non-minor Dependent" - California

What Is Form AD512NMD?

This is a legal form that was released by the California Department of Social Services - 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 August 1, 2013;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AD512NMD by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form AD512NMD "Psychosocial and Medical History of Non-minor Dependent" - California

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This document contains both information and form fields. To read information, use the Down Arrow from a form field.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PSYCHOSOCIAL AND MEDICAL HISTORY OF NON-MINOR DEPENDENT
SEX
NON-MINOR DEPENDENT’S ADOPTED NAME:
n
n
MALE
FEMALE
AGE OF NON-MINOR DEPENDENT”:
BIRTHDATE:
BIRTHPLACE:
COMPLETED BY:
DATE COMPLETED:
CASE NO./AGENCY ID:
Any documents attached to this form shall comply with the Mutual Disclosure Acknowledgment (AD 513 NMD) signed by non-minor
dependent.
The caseworker of the agency conducting the non-minor dependent assessment shall identify, by writting his or her initials in the space
provided, which items listed below are attached to this form.
______
Mutual Disclosure Acknowledgement (AD 513 NMD)
______
Non-minor dependent’s birth mother’s background information (AD 67 and narrative description)
Non-minor dependent’s father’s background information: (AD 67a and narrative description)
______
______
Non-minor dependent’s birth records. Name of Hospital:___________________________________________
______
Non-minor dependent’s post-birth medical care records.
The following medical records are attached: (Attach additional page(s) if needed)
NAME OF PROVIDER
TYPE OF PROVIDER
DATES
______
DEVELOPMENTAL AND BEHAVIORAL HISTORY
The following evaluations or assessments regarding the non-minor dependent’s developmental, cognitive, emotional
and/or behavioral functioning are attached:
TYPE OF REPORT
PROVIDER
DATE OF REPORT
Non-minor dependent’s foster care Health And Education Passport (CWS/CMS document and any related documentation)
______
______
Non-minor dependent’s placement history
______
Non-minor dependent’s history / family life experience prior to out-of-home care
(Including History Of Abuse Or Neglect)
AD 512NMD (8/13)
Page 1 of 2
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PSYCHOSOCIAL AND MEDICAL HISTORY OF NON-MINOR DEPENDENT
SEX
NON-MINOR DEPENDENT’S ADOPTED NAME:
n
n
MALE
FEMALE
AGE OF NON-MINOR DEPENDENT”:
BIRTHDATE:
BIRTHPLACE:
COMPLETED BY:
DATE COMPLETED:
CASE NO./AGENCY ID:
Any documents attached to this form shall comply with the Mutual Disclosure Acknowledgment (AD 513 NMD) signed by non-minor
dependent.
The caseworker of the agency conducting the non-minor dependent assessment shall identify, by writting his or her initials in the space
provided, which items listed below are attached to this form.
______
Mutual Disclosure Acknowledgement (AD 513 NMD)
______
Non-minor dependent’s birth mother’s background information (AD 67 and narrative description)
Non-minor dependent’s father’s background information: (AD 67a and narrative description)
______
______
Non-minor dependent’s birth records. Name of Hospital:___________________________________________
______
Non-minor dependent’s post-birth medical care records.
The following medical records are attached: (Attach additional page(s) if needed)
NAME OF PROVIDER
TYPE OF PROVIDER
DATES
______
DEVELOPMENTAL AND BEHAVIORAL HISTORY
The following evaluations or assessments regarding the non-minor dependent’s developmental, cognitive, emotional
and/or behavioral functioning are attached:
TYPE OF REPORT
PROVIDER
DATE OF REPORT
Non-minor dependent’s foster care Health And Education Passport (CWS/CMS document and any related documentation)
______
______
Non-minor dependent’s placement history
______
Non-minor dependent’s history / family life experience prior to out-of-home care
(Including History Of Abuse Or Neglect)
AD 512NMD (8/13)
Page 1 of 2
PSYCHOSOCIAL AND MEDICAL HISTORY OF NON-MINOR DEPENDENT (continuation)
The Following Additional Reports Are Attached:
TYPE OF REPORT
PROVIDER
DATE OF REPORT
______
The agency’s recommendations/comments to the non-minor dependent (attach additional page if needed)
The following records or documents are unavailable:
RECORDS/REPORTS
DATE(S)
REASON UNAVAILABLE
The non-minor dependent adoptee has been provided with all medical, psychological and social background information
available to the department or agency as permitted by the signed disclosure.
AGENCY
DATE
CASE WORKER
Notice to Non-Minor Dependent
Based on the agency’s evaluation, the agency believes the attached information is true and accurate as far as it is aware.
California law requires that a non-minor dependent hold the privilege to their psychosocial and medical background and that they can then
decide what they wish to share or reveal to their prospective adoptive parent(s). This form and the attached documents are provided to
meet that requirement. Your signature below verifies your receipt of this information.
I ACKNOWLEDGE THAT I HAVE IN MY POSSESSION ALL THE ABOVE LISTED DOCUMENTS.
NON-MINOR DEPENDENT
DATE
Page 2 of 2
AD 512 NMD (8/13)
Page of 2