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F.C.A. §§360.2, 360.3 Form 3-41(Juvenile Delinquency - Order on Violation of Probation or Conditional Discharge) 12/2015At a term of the Family Court of the State of New York, held in and for the County of ,at New Yorkon , .PRESENT: Hon. Judge __________________________________In the Matter ofDocket No.A Person Alleged to be aORDER (ViolationJuvenile Delinquent, of Order of Probation or Conditional Discharge) Respondent. ___________________________________The above-named Respondent, having been adjudicated by this Court to be a juveniledelinquent within the meaning of Article 3 of the Family Court Act; and an Order of Disposition, dated , , having been made herein whereby Respondent was [check applicable box]:  placed on probation  conditionally discharged, upon certain terms and conditions;And the Presentment Agency having appeared, And the Respondent having  appeared  not appeared, And Counsel for the Respondent having  appeared  not appeared, And the Respondent having had an opportunity to be heard;The Court, after hearing, being satisfied by competent proof that the Respondent, [check applicable box]:  did  did notwillfully and without just cause fail to comply with the terms and conditions in that: [specify provisions of order violated and nature of violations]: [Required where Order of Disposition is revoked]:And the Court, having determined that the Order of Disposition should be revoked andhaving fully considered the matter of a new disposition pursuant to Family Court Act §§ 352.2 and360.3, determines that the Respondent requires the following disposition for the following reasons[specify; if the Respondent has been found to be sexually exploited, as defined in Social Services Law§447-a, so indicate]: Form 3-41 Page 2Required Findings in Cases in Which the Respondent is Placed [The following determinations are required when Respondent is placed pursuant to F.C.A. §353.3; check applicable boxes and provide case-specific reasons]: The Court finds and determines that:A. Best Interests Finding: Continuation in or return to the Respondent’s home  would  would not be contrary to Respondent’s best interests based upon the following facts andfor the following reasons [specify]: This determination is based upon the following information [check applicable box(es)]: Uniform Case Record, dated [specify]: Summary of the Uniform Case Record, dated [specify]: Service Plan, dated [specify]: Risk Assessment Instrument Probation Department report, dated [specify]: Mental health evaluation, dated [specify]: The report of [specify]: , dated [specify]: Testimony of [specify]: Other [specify]:B. Reasonable Efforts Findings: 1. Reasonable efforts, where appropriate and consistent with the need for protection of thecommunity, to prevent or eliminate the need for removal of Respondent from the home, and, if theRespondent was removed prior to the date of the dispositional hearing regarding the violation, to returnRespondent safely to his or her home: were made as follows [specify]: were not made but the lack of efforts was appropriate [check all applicable boxes]:  because of a prior judicial finding pursuant to Family Court Act §352.2(2)(c)thatthe authorized agency was not required to make reasonable efforts to reunify theRespondent with the  parent(s)  guardian(s) [specify date of finding]:  because of other reasons [specify]: were not made.This determination is based upon the following information [check applicable box(es)]: Uniform Case Record, dated [specify]: Summary of the Uniform Case Record, dated [specify]: Service Plan, dated [specify]: Risk Assessment Instrument Probation Department report, dated [specify]: Mental health evaluation, dated [specify]: The report of [specify]: , dated [specify]: Testimony of [specify]: Form 3-41 Page 3 Other [specify]: 2. [Applicable in cases in which the Respondent’s permanency plan is adoption, guardianship orpermanent living arrangement other than reunification]: Reasonable efforts to make and finalize thepermanency plan of [specify]:  were made as follows [specify]:  were not made based upon the following facts and for the following reasons [specify; if lack ofefforts was reasonable, so indicate]: This determination was based upon the following information [check applicable box(es)]: Uniform Case Record, dated [specify]: Summary of the Uniform Case Record, dated [specify]: Service Plan, dated [specify]: Risk Assessment Instrument Probation Department report, dated [specify]: Mental health evaluation, dated [specify]: The report of [specify]: , dated [specify]: Testimony of [specify]: Other [specify]:C. Findings Regarding Transitional Services and Out-of-State Placements: [Required where Respondent is 14 years of age or older]: The services, if any, neededto assist the Respondent to make the transition from foster care to independent living are [specify]: [Required where the Respondent is placed outside New York State]: Placement outsideNew York State  is  is not appropriate and in the Respondent’s best interests.D. Findings Regarding Pre-dispositional Risk Assessment Instrument:There  is  is not a validated pre-dispositional risk assessment instrument in use in thiscounty that was developed by (or in New York City, approved by) the New York State Office ofChildren and Family Services.[REQUIRED where there is a validated pre-dispositional risk assessment instrument in use]:Respondent has been assessed on the risk assessment instrument as a [check box for level of risk]:[NYC cases only]:  low  medium  high  very high level of risk [NON-NYC cases only]:  low  medium  high level of risk . [REQUIRED where validated pre-dispositional risk assessment instrument is in use andwhere placement is at a higher level of care than the assessed risk level; omit if inapplicable]:  Placement, as directed below, is necessary and no less restrictive alternative is available,both for the protection of the community and to be consistent with the needs and best interests of theRespondent, notwithstanding the assessed risk level, for the following reasons {specify]: Form 3-41 Page 4 NOW, therefore, it is hereby ORDERED, that the Order of Disposition is  vacated  continued ; (and it is further) ORDERED that [check applicable boxes]: Respondent is discharged with a warning. Respondent is conditionally discharged for a period of [specify]: months uponthe following terms and conditions: Respondent is placed on probation under the supervision of the Probation Department ofthe County of [specify]: for a period of [specify]: upon thefollowing terms and conditions:1 The probation service shall report to the court Q orally Q in writing on [specify date]: and every ___ days thereafter concerning Respondent's compliance with the terms and conditions ofthis order.[Applicable where Respondent is directly placed with a suitable relative or other person]:  This proceeding is continued and the Respondent is placed for a period of [specify]:  less the period spent in detention pending disposition)2 in the custody of [specifysuitable relative or other person]: , subject to the further orders of this Court.[REQUIRED where Respondent is placed in non-secure or limited-secure level of care]: This proceeding is continued and Respondent is placed in a non-secure level of care for aperiod of [specify period]:  less the period spent in detention pendingdisposition,3 in the custody of the Commissioner of the [check applicable box]: [Non-NYC cases only]:  Department of Social Services of the County of [specify]:  New York State Office of Children and Family Services [NYC cases only]:  New York City Administration for Children’s Services. This proceeding is continued and Respondent is placed in a limited secure level of care for a period of [specify period]:  less the period spent in detention pending2 Applicable unless all or part of such credit would not serve the needs and best interests of the Respondentor the need for protection of the community. See F.C.A §353.3(5).3Applicable unless all or part of such credit would not serve the best interests of the Respondent or the needfor protection of the community. See F.C.A. §353.3(5). Note that in all placement cases, the placement period maybe tolled by reason of the Respondent’s absence without leave. Form 3-41 Page 5disposition,4 in the custody of the Commissioner of the [check applicable box]: [Non-NYC cases only]:  New York State Office of Children and Family Services[NYC cases only]:  New York City Administration for Children’s Services. [NYC cases only]: This proceeding is continued and Respondent is placed in the custody of theNew York City Administration for Children’s Services in a non-secure OR limited secure level of care,the level to be determined by the Commissioner, for a period of [specify period up to 12 months]:  less the period spent in detention pending disposition.5[NON-NYC cases only; applicable where Respondent is placed with Department of SocialServices for non-secure level of care in a specific agency or class of agency]: The position of the Commissioner of Social Services of the County of [specify]: having been considered by the Court, this proceeding is continued and Respondent is placed for aperiod of [specify period]: less the period spent in detention pendingdisposition,6 in the custody of the Commissioner of Social Services of the County of [specify]: , for non-secure placement with [specify agency or class of agency; note: if the Respondenthas been found to be sexually exploited, as defined in Social Services Law §447-a, so indicate ifRespondent should be placed in an available long-term safe house]: , subject to the further orders of this Court. In the event that the Commissioner of Social Services is unable to so place the child, the Commissioner[check applicable box]:  shall  need not apply to the Court for an order to stay, modify, set aside or vacate the order pursuant to Family Court Act § 762.  shall  need not return Respondent to this Court for a new dispositional hearing. [NYC cases only; applicable where Respondent is placed with the NYC Administration forChildren’s Services for non-secure or limited-secure level of care where specific services areneeded]: The Commissioner of the New York City Administration for Children’s Services is directed toprovide the following services, authorized or required to be made available in the approved plan for the“Close to Home” program, to meet the needs of the Respondent [specify; note: if the Respondent hasbeen found to be sexually exploited, as defined in Social Services Law §447-a, so indicate ifRespondent needs the services afforded by an available long-term safe house]: 4Applicable unless all or part of such credit would not serve the best interests of the Respondent or the needfor protection of the community. See F.C.A. §353.3(5). Note that in all placement cases, the placement period maybe tolled by reason of the Respondent’s absence without leave.5Applicable unless all or part of such credit would not serve the best interests of the Respondent or the needfor protection of the community. See F.C.A. §353.3(5). Note that in all placement cases, the placement period maybe tolled by reason of the Respondent’s absence without leave.6Applicable unless all or part of such credit would not serve the best interests of the Respondent or the needfor protection of the community. See F.C.A. §353.3(5) Form 3-41 Page 6[The following three paragraphs are applicable where Respondent is placed with the New YorkState Office of Children and Family Services; note: in New York City cases, these paragraphsare applicable only to a Respondent placed in a secure level of care]:  This proceeding is continued and the Respondent is placed for a period of [specify]:  less theperiod spent in detention pending disposition,7 in the custody of the New York State Office ofChildren and Family Services, which is authorized to place the Respondent in a [specify]:  secure facility at any time or from time to time during the first 60 days of residency;8  limited secure facility [non-NYC cases only]  non-secure facility [non-NYC cases only] subject to further orders of this Court.  [NON-NYC cases only] The position of the New York State Office of Children and Family Serviceshaving been considered by the Court, this proceeding is continued and the Respondent is placed for aperiod of [specify]:  less the period spent in detention pending disposition,9 in thecustody of the New York State Office of Children and Family Services for placement with [specifyagency or class of agency; note: if the Respondent has been found to be sexually exploited, as definedin Social Services Law §447-a, so indicate if Respondent should be placed in an available long-termsafe house]: , subject to further orders of this Court. In the eventthat the New York State Office of Children and Family Services is unable to place the Respondent inaccordance with the direction hereof, or discontinues the placement with the authorized agency, theRespondent shall be deemed to have been placed with the New York State Office of Children andFamily Services pursuant to paragraph (b) or (c) of subdivision three of section 353.3 of the FamilyCourt Act. In such cases, the New York State Office of Children and Family Services shall notify thecourt, Presentment Agency, counsel for the Respondent and parent or other person responsible for theRespondent’s care, of the reason for discontinuing the placement with the authorized agency and thelevel and location of the youth’s placement.[Optional where Respondent is placed with the New York State Office of Children and FamilyServices; check box if applicable]: The New York State Office of Children and Family Services shall photograph theRespondent pursuant to Executive Law § 507-a(3). [Optional where Respondent is 14 years of age or older and is placed with the New York StateOffice of Children and Family Services, the New York City Administration for Children’sServices or Commissioner of Social Services; check box if applicable ]: The placement agency is directed to provide the following services determined above tobe needed to assist the child to make the transition from foster care to independent living [specify]: 7 Applicable unless all or part of such credit would not serve the needs and best interests of the Respondentor the need for protection of the community. See F.C.A. §353.3(5).8 See F.C.A. §353.3(3)(a).9 Applicable unless all or part of such credit would not serve the needs and best interestsof the Respondent or the need for protection of the community. See F.C.A. §353.3(5). Form 3-41 Page 7[Optional where Respondent, after adjudication for an act that would be a felony if committedby an adult, is placed with the New York State Office of Children and Family Services or theNew York City Administration for Children’s Services pursuant to F.C.A.§353.3(9); check box ifapplicable]:  Respondent shall be confined in a residential facility for a minimum period of [specifyminimum period not to exceed six months]: [Required where Respondent is placed with the New York City Administration for Children’sServices; optional for all other placement cases; check box if applicable]:  The placement agency is directed to provide prior notice to the Respondent, attorney forthe Respondent and Respondent’s parent or guardian in the event that Respondent is transferred fromone facility to another, unless an immediate change of placement is necessary, in which case the noticeshall be transmitted on the next business day. [Required where Respondent is placed with the New York State Office of Children and FamilyServices, the New York City Administration for Children’s Services or a local social servicesdistrict; check applicable boxes]:  Respondent’s parent or legal guardian was present in Court and consented to theprovision of routine medical, dental and mental health services and treatment to the Respondent by the:  New York State Office of Children and Family Services  New York City Administration forChildren’s Services  Department of Social Services, County of [specify]: ;OR  Consent has not been obtained from Respondent’s parent or legal guardian, but this Ordershall be deemed to grant consent for the :  New York State Office of Children and Family Services  New York City Administration for Children’s Services  Department of Social Services, County of[specify]: to provide routine medical, dental and mental health services and treatment tothe Respondent. [Required where Respondent is placed non-securely with the Commissioner of a CountyDepartment of Social Services, the New York City Administration for Children’s Services or theNew York State Office of Children and Family Services, pursuant to F.C.A.§353.3 or §353.4;check box if applicable]:  ORDERED that if the Respondent remains in foster care, the [check box]: New York State Office of Children and Family Services;  Commissioner of Social Services of [specify]: County;  New York City Administration for Children’s Services shall file a petition for the next permanency hearing NO LATER THAN [specify date not lessthan 60 days before permanency hearing must be completed]: and the permanency hearing shall be completed by [specify date]:1010A petition for a permanency hearing shall be filed 60 days prior to the expiration of the placement or 60days prior to end of 12 months following the entry of the child into foster care, whichever is earlier. TheRespondent shall be deemed to have entered foster care 60 days following removal from the home. See F.C.A.§355.5(4). Except in cases where the permanency hearing is required prior to an extension of placement –e.g., 18-month felony placements or cases in which a determination is made that reasonable efforts are not required pursuant Form 3-41 Page 8 (and it is further) ORDERED .PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THISORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANTIN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BYTHE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEYFOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST.ENTER _________________________________________ Judge of the Family Court Dated: , .Check applicable box:  Order mailed on [specify date(s) and to whom mailed ]:___________________________  Order received in court on [specify date(s) and to whom given]:_____________________ to F.C.A. §352.2(2)(c) – the permanency hearing petition shall be combined with the petition for extension ofplacement. See F.C.A. §355.5(2).