Fill and Sign the Colorado Relinquishment Counseling Form

 District Court  Denver Juvenile Court _____________________County, Colorado Court Address: In the Matter of the Petition of: __________________________________________________ And ____________________________________________Petitioner(s) For the Relinquishment of a Child, _______________________________________________________ (child’s name) COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom AFFIDAVIT OF RELINQUISHMENT COUNSELING I, of County Department of Social Services/Child Placement Agency, state that I provided counseling to on the following dates _______________________________ concerning the Petitioner’s Petition for Relinquishment. 1. The nature and extent of counseling included the following:  Information to Petitioner concerning the permanence of the decision to relinquish and the impact of the decision on Petitioner now and in the future.  Information was obtained from Petitioner about the complete medical and social histories of both of the child’s parents.  If Petitioner was pregnant, the Petitioner was referred for medical care and a determination of eligibility for medical assistance.  Information about alternatives to relinquishment and a referral to private and public resources that may meet the parents’ needs.  Information about relinquishment services necessary to protect the interests and welfare of the child if the child was born in a state institution.  Information that if Petitioner applies for public assistance for Petitioner or the child, Petitioner must cooperate with the Child Support Enforcement Unit for the establishment of a child support order.  That all information, except non-identifying information as defined in §19-1-103(80), C.R.S., obtained in the course of relinquishment counseling, is confidential, unless the parent provides written information or a court orders a release of information.  Other counseling provided: JDF 453 R3/18 AFFIDAVIT OF RELINQUISHMENT COUNSELING Page 1 of 2 2. The Affiant has prepared a report as “Exhibit A” that outlines the process of relinquishment counseling in more detail.  By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form.  By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of ________________, _______, at ______________________________________ (date) (month) (year) (city or other location, and state OR country ___________________________________ ______________________________________ (printed name of Counselor) Signature of Counselor JDF 453 R3/18 AFFIDAVIT OF RELINQUISHMENT COUNSELING Page 2 of 2