Fill and Sign the Guardian Ad Litem 497312759 Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type: Parental Notification In the Matter of the Petition of: Report of the Guardian Ad Litem or Petitioner Date of Birth: I. MEDICAL INFORMATION 1. Has the Petitioner been examined by a physician?  Yes  No Date: 2. Have the abortion procedures and the medical risks been explained?  Yes  No 3. Have the aftercare procedures been explained and understood?  Yes  No 4. Has the Petitioner been informed and does Petitioner understand what to do if medical complications occur?  Yes  No 5. Has the Petitioner given a true statement of her medical history to the physician?  Yes  No 6. Did Petitioner’s physician advise her of any additional risks to her  Yes  No health as a result of her medical history? 7. Has the Petitioner given informed consent to the abortion?  Yes  No II. COUNSELING INFORMATION 1. Has Petitioner received counseling regarding having an abortion?  Yes  No If yes, name and agency of counselor; 2. Has Petitioner received counseling as to pregnancy alternatives? a. abortion  Yes  No b. adoption  Yes  No JUV202 State ENG Rev 01/02-D www.courts.state.mn.us/forms Page 1 of 4 c. marriage  Yes  No d. single parenthood  Yes  No 3. Does Petitoner feel she needs more counseling as to her decision to a. have an abortion?  Yes  No 4. Has Petitioner been counseled as to possible emotional and psychological a. Problems she may experience after the abortion?  Yes  No 5. Has Petitioner been counseled as to the methods of contraception that a. are available?  Yes  No III. PERSONAL INFORMATION 1. Does Petitioner wish to have an abortion?  Yes  No 2. Has Petitioner been coerced by any other party as to this decision?  Yes  No 3. Petitioner elects not to notify her parent(s) because: 4. Does Petitioner live with her parents?  Yes  No 5. What is Petitioner’s source of financial income? 6. Is Petitioner attending school? Grade  Yes  No 7. What is the highest school grade level Petitioner has completed? 8. Is Petitioner employed?  Yes  No 9. Place of employment: Address JUV202 State ENG Rev 01/02-D www.courts.state.mn.us/forms Page 2 of 4 Job title: 10. What are Petitioner’s plans for the future (schooling, employment, etc.)? 11. State any additional information Petitioner wishes to bring to the court’s attention relative to the proposed abortion: Dated: Guardian Ad Litem on behalf of Petition or Petitioner Relationship to Minor JUV202 State ENG Rev 01/02-D www.courts.state.mn.us/forms Page 3 of 4 IV. RECOMMENDATION OF THE GUARDIAN AD LITEM A. Authorization to the physician without parental notification is recommended because: B. The minor is mature and capable of giving an informed consent, as evidenced by: C. The minor is not mature, but the proposed waiver of parental notification is in her best interests because: D. It is not recommended that authorization be granted because: Dated: Guardian Ad Litem JUV202 State ENG Rev 01/02-D www.courts.state.mn.us/forms Page 4 of 4