In order for a CASA volunteer to be appointed as the educational representative, a Judicial Council of California Form JV-535 limiting
the educational rights of the parent(s) must be signed by the judicial officer and filed with the Court.
Rev. 12/2017
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, Sate Bar Number, and Address)
TELEPHONE NO:
EMAIL ADDRESS (Optional):
Superior Court of California, County of San Francisco
Juvenile Justice Center
375 Woodside Avenue, Room 101, San Francisco, CA 94127
Civic Center Courthouse
400 McAllister Street, Room 402, San Francisco, CA 94102
CASE NAME:
PIN (if applicable):
REQUEST FOR COURT APPOINTED SPECIAL ADVOCATE (CASA)
AND/OR EDUCATIONAL RIGHTS HOLDER REFERRAL
1. N
ame of Youth: __________________________________________________ Date of Birth: _________________
2. Gender Identity: ___________________ Race: _____________________ Ethnicity: _________________________
3. Current Placement City: ________________________________ Primary language(s): ______________________
4. Current HSA-FCS PSW and/or JPD PO or SW: ______________________________________________________
5. Attorney(s) for Youth: ______________________________________ Anticipated Disposition Date: ____________
6. City and/or District Attorney: _____________________________________________________________________
7. Court Proceedings Stage and Current Case Plan: ____________________________________________________
8. Reason(s) for Referral (please check all applicable):
☐ Severity of maltreatment ☐ Re-entry to foster care as a minor
☐ Length of time in foster care (APPLA as permanent plan) ☐ Health or physical disability issues
☐ Mental health involvement ☐ Education issues
☐ Gang involvement ☐ EFC (Signed consent by NMD must be attached)
☐ Immigration issues ☐ Absence of permanency/permanent connections
☐ Witness to/Victim of a violent crime ☐ Juvenile justice involvement
☐ CSEC ☐ Social isolation
☐ LGBTQIA ☐ Incarcerated parent(s)
☐ Other (please explain below): _________________________________________________________________
9. P
lease describe the Youth’s Personality, Interests, Strengths and Needs (assists with matching):
____________________________________________________________________________________________
____________________________________________________________________________________________
I am requesting a:
☐ CASA ☐ Educational Rights Holder Date: ________________________________
Applicable parties noticed:
☐ Attorney for Dependent/Ward ☐ HSA-FCS ☐ JPD ☐ City and/or District Attorney
___________________________________________ ____________________________________________
Name of Referent and Relationship to Youth (Print) Signature of Referent
The Court hereby orders the approval of this Request for CASA and/or Educational Rights Holder through the San
Francisco Court Appointed Special Advocate Program.
______________________ _____________________________________________
Date Judge, Unified Family Court
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