Fill and Sign the General Form 13a

F.C.A.§ 251 General Form 13a (Order Directing Medical Examination)8/2010 At a term of the Family Court of the State of New York, held in and for the County of , at , New Yorkon ,. P R E S E N T: Hon. Judge...................................................................... In the Matter of a Proceeding under Docket No. Article of the Family Court Act ORDER DIRECTING MEDICAL EXAMINATION (INPATIENT) .................................................................... A petition under Article of the Family Court Act, sworn to on , , having been filed in this court in the above-entitled proceeding alleging that [specify]: and the matter having duly come on to be heard before this Court; and I. Required Determinations for Inpatient Examination [check applicable box(es)]: A.. This Court has jurisdiction over the petition and [specify person to be examined]: [Check applicable box]: “ is a person within the jurisdiction of this Court ; “ is a parent or other person legally responsible for the care of a child who is within the jurisdiction of this Court; and B. An examination of [specify name]: by a [check applicable box(es)]: “ physician “psychiatrist “ psychologist would serve the purpose of this Act; and C. The Director of an institution in the “ Office of Mental Health “ Office of Mental Retardation and Developmental Disabilities “ was “ was not afforded an opportunity to be heard before this Court. D. The “ adult to be examined “ attorney for the child representing the child to be examined “ consented “ did not consent to the examination. General Form 13a page 2 E. [Juvenile delinquency proceeding only]: An inpatient examination “ is “ is not necessary for a determination of possible incapacity under Family Court Act § 322.1. F. [Juvenile delinquency or PINS proceeding pending disposition only]: 1. This Court made an order of fact-finding under Article “ 3 “ 7 of the Family Court Act and determined in accordance with the criteria in Family Court Act “ § 320.5(3) “ § 739(a) that the child should be detained pending disposition; 2. This Court further found that the need for examination in a residential facility is supported by [specify]: and that [specify facility]: is the most appropriate facility for such examination. II. Required “Best Interests” and “Reasonable Efforts” Findings [Required in all cases in which the person to be remanded for examination is a child who is the Respondent in a proceeding under Articles 3 or 7 of the Family Court Act or who is the subject of a proceeding under Article 10 of the Family Court Act or Social Services Law §§358-a, 384-b or 392; check applicable boxes, and provide case-specific reasons in both A and B, below. If findings were previously made, so specify]: A. Continued placement in the Respondent’s home [check applicable box]: Qwould Qwould not be contrary to the Respondent’s best interests, based upon the following facts and for the following specific reasons [specify particular facts and reasons]: Specific documents or evidence supporting this finding include the following: “ Mental health evaluation, dated [specify]: “ Testimony of [specify]: “ Other [specify]: ; AND B. Reasonable efforts, where appropriate, to prevent or eliminate the need for removal of the Respondent from the home, and , if the Respondent was removed prior to the date of the hearing, to return the Respondent safely to his or her home: “ were made as follows [specify reasonable efforts]: “ were not made but the lack of such efforts was appropriate based upon the following facts and for the following reasons [specify particular facts and reasons]: “ were not made. Specific documents or evidence supporting the finding in ¶B include the following:“ Mental health evaluation, dated [specify]: “ Testimony of [specify]: “ Other [specify]: General Form 13a page 3 NOW, THEREFORE, it is ORDERED that [specify]: is remanded to [check applicable box]: “ The following Department of Health facility in the City of New York maintained for the purpose of such an examination [specify]: “ The following hospital [specify]: maintained by “ County [specify]: “ State of New York “ a qualified private institution approved for such purpose and operating under contract with [specify agency; delete if inapplicable]: “ The following institution, operated by the Department of Office of Mental Health or Office of Mental Retardation and Developmental Disabilities, for examination [specify]: ;And it is further ORDERED that the remand for examination shall be for a period determined by the facility, which shall not exceed 30 days; and it is further ORDERED that upon completion of the examination ordered herein, if hospitalization is not required, the person examined shall be [specify]: ; and it is further ORDERED that shall, within days after the completion of such examination, submit a report thereof to this Court; (and it is further). ( ORDERED: .) PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. ENTER ____________________________________ Judge of the Family Court Dated: , . Check applicable box: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to whom given]:_____________________