JV-215, Page 1 of 2
Judicial Council of California, www.courts.ca.gov
New September 1, 2018, Mandatory Form
Welfare and Institutions Code, § 14717.1
Order After Hearing on
Waiver of Presumptive Transfer
Order After Hearing on Waiver of
Presumptive Transfer
JV-215
The social worker / probation officer provided a report no later than two days after a hearing was granted. The
report included the information as required by rule 5.647(d) of the California Rules of Court.
The child or nonminor:
a.
Is being placed in a county outside the county of original jurisdiction on (date): .
The court has read and considered the report.
a.
Hearing date:
Time:
Dept.:
Room:
b.
Judicial officer:
c.
The Court Finds and Orders
b.
Was placed in a county outside the county of original jurisdiction on (date): .
Party (name):
(1)
Child:
Present
Attorney:
(2)
Mother:
Attorney:
(3)
Father-presumed:
Attorney:
(4)
Father-biological:
Attorney:
(5)
Father-alleged:
Attorney:
(6)
Legal guardian:
Attorney:
(7)
Indian custodian:
Attorney:
(8)
De facto parent:
Attorney:
(9)
County agency social worker:
Attorney:
(10)
Tribal representative:
Attorney:
(11)
Other (specify):
Attorney:
A request for a waiver to presumptive transfer was made to the placing agency by: .
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Court fills in case number when form is filed.
Case Number:
Fill in child's name and date of birth:
Child's/Nonminor's Name:
Date of Birth:
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a.
(1)
The transfer would disrupt continuity of care or delay access to services provided to the child or
nonminor.
(2)
The transfer would interfere with family reunification efforts documented in the individual case plan.
The placing agency has determined an exception to the presumptive transfer of the responsibility to provide
for and arrange for the child’s or nonminor’s specialty mental health services:
b.
(3)
The child’s or nonminor’s placement in a county other than the county of original jurisdiction is
expected to last less than six months.
(4)
The child’s or nonminor’s residence is within 30 minutes of travel time to his or her established
specialty mental health care provider in the county of original jurisdiction.
The placing agency has determined that no exception applies to the presumptive transfer.
The placing agency consulted the child and family team and others who serve the child or nonminor as
appropriate regarding the waiver determination.
a.
Notice of the placing agency’s determination on the request to waive presumptive transfer of specialty mental
health services was provided to the individual who requested waiver of presumptive transfer, and to all parties
to the case.
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After having considered the basis for the request for a hearing, the report provided for the hearing, and any
other evidence presented at the hearing, the court finds that
is in the child’s or nonminor’s best interests.
waiver of presumptive transfer presumptive transfer
Date:
Judge (or Judicial Officer)
If waiver applies, the mental health plan in the county of original jurisdiction has an existing contract with a
specialty mental health care provider, or has demonstrated the ability to enter into a contract within 30 days
of the waiver decision and to deliver timely specialty mental health services directly to the child or
nonminor.
a.
The placing agency’s decision on the request for waiver of presumptive transfer was communicated by the
placing agency to the child and family team on (date): .
b.
b.
Case Number:
Child's/Nonminor's Name:
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JV-215, Page 2 of 2
New September 1, 2018, Mandatory Form
Order After Hearing on
Waiver of Presumptive Transfer
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