First/Dep Review/Perm Pla. Hrg Or (FDPRHO, DPRHO, ORPP ) - Page 1 of 14
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Superior Court of Washington
County of _______________________
Juvenile Court
Dependency of:
D.O.B.:
No :
Order after Hearing :
[ ] First Dependency Review (FDPRHO)
[ ] Dependency Review (DPRHO)
[ ] Permanency Planning (ORPP)
[ ] Clerk’s Action Required . Paragraphs
2.10 ([ ] CPR [ ] NSP [ ] CRD [ ] IPM
[ ] PCT [ ] NFA [ ] GCF), 3.13 (EDL/W DL),
and the boxes below.
The court will hear [ ] interim review [ ] dependency review [ ] permanency planning
[ ] _________________________ (type of hearing) on (date) _____________________ __ at _________
a.m./p.m. at: ___________________________________, Court, Room/Department: _______________,
located at: _________________________________________________________________________
______________________________________________________________ ____________________.
Additional Clerk’s Action Required: Enter the code(s) that apply .
About today’s hearing :
W as adequate and timely notice given to the child’s caregiver? Yes (CGATN) [ ] No (CGNATN) [ ]
Did the cour t receive a caregiver report? Yes (CGRR) [ ] / No [ ]
[ ] The caregiver appeared. Did the court give the caregiver an opportunity to be heard? Yes [ ] / No [ ]
I. Hearing
1.1 The court held a hearing on _____________________________________ [date] .
1.2 The following persons appeared at the hearing:
[ ] Child [ ] Child's Lawyer
[ ] Mother [ ] Mother's Lawyer
[ ] Father [ ] Father's Lawyer
[ ] Guardian or Legal Custodian [ ] Guardian's or Legal Custodian's Lawyer
[ ] Child's GAL [ ] GAL's Lawyer
[ ] DCYF W orker [ ] DCYF’s Lawyer
[ ] Tribal Representative [ ] Current Caregiver
[ ] Interpreter for [ ] mother [ ] father [ ] Child’s Educational Liaison
[ ] Other ___________________ [ ] Other ___________________________
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1.3 The order is [ ] agreed [ ] contested.
[ ] The court heard testimony from: ____________________________________________.
[ ] The child is 12 years old or older and t he court made the inquiry required by
RCW 13.34.100(7).
II. Findings
General
2.1 Child’s Indian status: [ ] On this date [ ] On _______________, the court asked each part icipant
on the record whether the participant knows or has reason to know the child is an Indian child.
[ ] There is not a reason to know the child is an Indian child as defined in RCW 13.38.040
and 25 U.S.C. § 1903(4), based upon prior fi ndings and order(s). The federal and
W ashington State Indian Child W elfare Acts do not apply to these proceedings.
[ ] There is reason to know the child is an Indian child as defined in RCW 13.38.040 and 25
U.S.C. § 1903(4), based upon prio r findings and order(s). The federal and W ashington
State Indian Child W elfare Acts apply to this proceeding. The notice and evidentiary
requirements of the federal and W ashington State Indian Child W elfare Acts were found
in previous hearings and are in corporated here by reference.
[ ] DCYF made active efforts by actively working with the parent, parents, or Indian
Custodian to engage them in remedial services and rehabilitative programs to prevent the
breakup of the Indian family beyond s imply providing referrals to such services, but those
efforts have been unsuccessful.
[ ] Other:
.
2.2 The child’s current caregiver was informed of this proceeding and his or her right to be heard by the
court as required by Chapter 13 .34 RCW .
2.3 [ ] Pursuant to RCW 13.34.030, the child was found to be dependent as to the [ ] mother
[ ] father [ ] guardian/legal custodian and a disposition order was entered.
2.4 [ ] In the previous review period, the permanency plan in effect for the child has been:
Primary: Alternative:
[ ] [ ] Return of the child to the home of the [ ] mother [ ] father
[ ] guardian or [ ] legal custodian;
[ ] [ ] Adoption;
[ ] [ ] Final non -parental custody order pursuant to Chapter 26.10 RCW or
the equivalent laws of another state or a feder ally recognized Indian
tribe;
[ ] [ ] Title 13 Guardianship
[ ] [ ] Long term [ ] relative or [ ] foster care, for children between 16 and
18 years of age, with a writ ten agreement;
[ ] [ ] Responsible living skills program; and/or
[ ] [ ] Independent living for children 16 and older.
2.5 The placement and permanent plan:
[ ] are still necess ary and appropriate for the safety and wellbeing of the child.
[ ] are no longer necessary and appropriate and the placement shall be modified as stated in
Paragraph 3.3.
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[ ] are no longer necessary and appropriate and the perma nent plan shall be modified as
stated in Paragraph 3.19.
[ ] have been accomplished because the court entered a parenting plan, residential
schedule, or nonparental custody decree, which is in the child’s best interests, and which
implements the permanent plan of care.
[ ] long -term foster or relative care has been achieved.
2.6 _____________________________ is the projected date for:
[ ] return of the child to his or her home.
[ ] placement for ado ption.
[ ] establishment of a guardianship.
[ ] implementation of the following alternate plan of care: ____________________________.
2.7 [ ] The child is 16 years old or older and the court has approved a permane ncy plan other than
Return Home, Adoption, Title 13 Guardianship, or final non -parental custody order pursuant to
chapter 26.10 RCW for the following compelling reasons:
________________________________________________________________________
_____________ ___________________________________________________________.
2.8 [ ] The child is 14 years old or older and the court makes the following findings:
[ ] The child was present for today’s hearing. The court consulted with the c hild in an age -
appropriate manner regarding ongoing opportunities to engage in age or developmentally
appropriate activities.
[ ] The child was not present for today’s hearing.
The child [ ] does [ ] does not h ave regular, ongoing opportunities to engage in age or
developmentally appropriate activities.
DCYF has taken the following steps to ensure the child’s placement is following the reasonable
and prudent parent standard as defined in 42 U.S.C. §675(10)(A):
.
2.9 DCYF [ ] has [ ] has not made reasonable efforts to implement and finalize the permanent plan
for the child.
2.10 [ ] The child has been in out -of-home care for 15 of the last 22 months since the date the
dependency petition was filed and:
[ ] termination petition has already been filed.
[ ] DCYF should file a termination petition pursuant to RCW 13.34.136(3).
[ ] A termination petition should be filed pursuan t to RCW 13.34.138(2)(d).
[ ] Good cause not to require the filing of a termination petition exists because of the
following:
(CPR) [ ] The child has been placed in the care of a relative.
(NSP) [ ] DCYF has not pr ovided the child’s family with the services that are
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(CRD) [ ] DCYF has documented a compelling reason as the basis for its
determination that filing a termination petition would not be in the
best interests of the child.
(IPM) [ ] The parent is incarcerated, or the parent’s prior incarceration is a
significant factor in why the child has been in foster care for 15 of
the last 22 months, DCYF has not documented another reason
why it wou ld be otherwise appropriate to file a petition, and the
parent maintains a meaningful role in the child’s life, because:
.
(PCT) [ ] The parent has been accepted into a dependency treatment
court program or long -term substance abuse or d ual diagnoses
treatment program and is demonstrating compliance with
treatment goals.
(NFA) [ ] The parent was court -ordered to complete services necessary for
the child’s safe return home. The parent filed a declaration under
penalty of per jury that the parent is financially unable to pay for
those court -ordered services and that DCYF was unwilling or
unable to pay for those services necessary for the child’s safe
return home.
(GCF) [ ] Other: _________________________________ ____________
___________________________________________________
___________________________________________________.
Reports
2.11 The DCYF report [ ] was [ ] was not timely submitted.
2.12 The child’s [ ] guard ian ad litem [ ] attorney [ ] has [ ] has not made a report to the court.
[ ] The guardian ad litem has met with or personally observed the child in the past review period.
[ ] The g uardian ad litem has not met with or personally observed the child in the past review
period because:
__________________________________________________________________________
__________________________________________________________________________.
2.1 3 [ ] The child’s educational liaison, (name) ____________________ [ ] has [ ] has not made a
report to the court.
[ ] The current educational liaison should continue.
[ ] It is no lon ger appropriate for the current educational liaison to continue because:
_______________________________________________________________.
DCYF recommends that the court appoint (name) ________________________ to
serve as the child’s educational liaison.
2.14 [ ] The following other parties submitted reports to the court:
__________________________________________________________________________.
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Placement
2.15 Placement of the child:
A. Return Home
[ ] The child has been r esiding in foster care. A reason for removal of the child as set forth
in RCW 13.34.130(2) no longer exists and the child should be placed in the home of
the [ ] mother [ ] father under the supervision of DCYF and the continu ing jurisdiction of
the court.
[ ] DCYF [ ] has [ ] has not identified all adults known to be residing in the home and [ ]
has [ ] has not conducted background checks on those persons.
[ ] The [ ] mother [ ] father has identified the following persons as potential caregivers for
the child:
______________________________________________________________________
__________________________________ ____________________________________.
B. In Home
[ ] The child has been placed in the home of the [ ] mother [ ] father for a period of six
months.
[ ] The dependency should be dismissed. Th e permanency plan of return to the [ ] mother
[ ] father has been achieved and court supervision is not needed.
[ ] Court supervision should remain in effect. The placement of the child with the
[ ] mother [ ] father should remain in effect under the supervision of DCYF subject to
further review by the court.
C. Out of Home
[ ] Currently out of the home: The child remains placed out of home. There is a continu ing
need for out -of-home placement for the child and it would be contrary to the child's
welfare to return home. The child should remain in the custody, control and care of
[ ] DCYF [ ] a relative [ ] an other su itable person to be placed or remain in:
[ ] Relative care with ___________________________________ (name).
[ ] Relative placement, although preferred, is not in the best interest of the child and
the child shall continue or be placed in:
[ ] Foster care.
[ ] Placement with a suitable person _________________________ (name).
[ ] Placement with an a doptive parent or other person with whom the child’s siblings
or half -siblings live.
[ ] Other:
[ ] To be removed from the home now: The child was in the home and is now removed from
the home. It is currently contrary to the child’s welfare to remain in the home.
Reasonable efforts have been made to prevent t he removal of the child and were
unsuccessful. The child should be placed in the custody, control, and care of:
[ ] DCYF for placement in:
[ ] Relative care with ___________________________________ (name).
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[ ] Relative placement, although preferred, is not in the best interest of the child
and the child shall continue or be placed in:
[ ] Foster care:
[ ] pending completion of DCYF investigation of relative placement options.
[ ] because there is no relative or other suitable person who is willing,
appropriate, and available to care for the child, with whom the child has a
relationship and is comfortable.
[ ] because there is reasonable cause to believe that relative placement
would jeopardize the safety or welfare of the child and/or hinder efforts to
reunite the parent(s) and child.
[ ] Placement with a suitable person _________________________ (name).
[ ] Placement with an adoptive parent or other person with whom the child’s
siblings or half -siblings live.
[ ] Other:
[ ] A relative or other suitable person.
DCYF recommends a change in placement for the following reasons:
_______________________ _______________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
[ ] The child is an Indian child as defined in RCW 13.38.040, and this placement complies
with the placement priorities in RCW 13.38.180, and 25 U.S.C. §1915.
[ ] The child [ ] is [ ] is not in a safe and appropriate placement that adequate ly meets all
his or her physical, emotional, cultural, and educational needs.
[ ] DCYF [ ] has [ ] has not considered out -of-state placements for the child.
[ ] There are no appropriate out -of-stat e placements at this time.
[ ] Other:
________________________________________________________________
________________________________________________________________.
[ ] The [ ] mother’s [ ] fat her’s homelessness or lack of suitable housing is a significant
factor delaying permanency for the child by preventing the return of the child to the home
of the child’s parent.
[ ] DCYF should provide housing assistance.
Compliance and Pr ogress
2.16 DCYF [ ] has [ ] has not made reasonable efforts to provide services to the family and eliminate
the need for out -of-home placement of the child.
A. Compliance with Court Order
Agency ____________ [ ] yes [ ] no [ ] partial: _____________________________________
Mother _____________ [ ] yes [ ] no [ ] partial: _____________________________________
Father _____________ [ ] yes [ ] no [ ] partial: _____________________________________
Father _____________ [ ] yes [ ] no [ ] partial: _____________________________________
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Father _________ ____ [ ] yes [ ] no [ ] partial: _____________________________________
Child ______________ [ ] yes [ ] no N/A: ____________ [ ] partial: ____________________
Other (guardian or intervenor) _____________________ [ ] yes [ ] no [ ] partial: ___________
B. Progress toward correcting the problems that necessitated the child’s placement in
out -of-home care :
Mother_____________ [ ] yes [ ] no [ ] __________________________________________
Father _____________ [ ] yes [ ] no [ ] __________________________________________
Father _____________ [ ] yes [ ] no [ ] __________________________________________
Father _____________ [ ] yes [ ] no [ ] __________________________________________
Child _____________ [ ] yes [ ] no [ ] __________________________________________
Other (guardian or intervenor) _____________________ [ ] yes [ ] no [ ] __________________.
Visitation
2.17 [ ] The mother [ ] has [ ] has not visited the child on a regular basis.
[ ] Reasons why visits have not occurred or have been infrequent:
_______________________________________________________________ _____
____________________________________________________________________
____________________________________________________________________.
2.18 [ ] The father [ ] has [ ] has not visited the child on a regu lar basis.
[ ] Reasons why visits have not occurred or have been infrequent:
____________________________________________________________________
____________________________________________________________________
_____________________ ______________________________________________.
2.19 [ ] The child is placed out of the home and the court has considered the child’s placement,
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Placement wi th, contact, or visits between siblings:
[ ] has occurred (specify):_____________________________________________
_______________________________________________________________.
[ ] has not occurred because:
[ ] there is reasonable cause to believe that the best interests of the child or
siblings would be jeopardized,
[ ] the court does not have jurisdiction over the siblings in question and the
parents are not willing to agree to a plan, or
[ ] efforts to reunify the parent with the child would be hindered by such
placement, contact, or visitation.
[ ] Other: ___________________________________________________
_________________________________________________ _______.
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Permanency Planning Findings – Required at Permanency Planning Hearing
2.20 The permanent plan for the child [ ] has [ ] has not been achieved
2.21 The court [ ] has [ ] has not consulted with the child in an age -appropriate manner about the
proposed permanency or transition plan.
2.22 Service providers [ ] have [ ] have not been involved in planning to meet the special needs of the
child and the child’s paren t.
2.23 [ ] The child is age 14 years old or older and the court makes the following findings:
[ ] The child was present for today’s hearing. The court asked the child about the child’s desired
permanency outcome and consulte d with the child in an age -appropriate manner about the
proposed permanency and transition plan.
[
] The child was not present for today’s hearing. DCYF consulted with the child regarding the
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The following services are needed to assist the child in transitioning to successful adulthood:
.
2.24 [ ] The permanency plan identifies independent living as a goal and services should be
provided to assist the child in making a trans ition from foster care to independent living
and allow the child to manage his or her financial, personal, social, educational, and non -
financial affairs.
DCYF [ ] has [ ] has not identified specific services to be provided to assist the child in
making a transition from foster care to independent living.
2.25 [ ] The child has been placed in the home of the [ ] mother [ ] father for a period of at least
six months.
[ ] The permanent plan of return to the [ ] mother [ ] father has been achieved and
court supervision is not needed.
[ ] Court supervision should remain in effect. The placement of the child with the
[ ] mother [ ] father is continued under the supervision of the court until the next
review hearing.
[ ] The following conditions apply to the continued placement of the child with the
[ ] mother [ ] father:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_________________________________________________________ ______.
Other
2.26 [ ] The child is legally free and it has been six months or more since all parental rights were
terminated. The court shall appoint an attorney by separate order.
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2.27 Other :
____________________________________________ ________________________________
____________________________________________________________________________
____________________________________________________________________________
_____________________________________________________________________ _______
____________________________________________________________________________.
III. Order
Placement
3.1 [ ] The child remains a dependent child pursuant to RCW 13.34.030(6) [ ] (a) [ ] (b) [ ] (c).
Court supervision shall continue.
3.2 [ ] An Order Dismissing Dependency shall be entered.
3.3 [ ] The child shall be in the custody, control, and care of DCYF for placement in:
[ ] Foster care.
[ ] Relative placement with __________________________________________(name).
[ ] The home of a suitable person ____________________________________(name).
[ ] The home of an adoptive parent or other person with whom the child’s siblings or half -
siblings live.
[ ] The home of the [ ] mother [ ] father for a trial return home under the continued
supervision of the court.
[ ] Placement of the child in the [ ] mother’s [ ] father’s home is contingent upon the
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child, including compliance with the DCYF case plan, and the
[ ] mother’s [ ] father’s continued participation in [ ] substance abuse [ ] mental
health treatment [ ] other services:
DCYF may remove the child from the home, subject to review by the court, if the
parent fails to com ply with the DCYF plan or court order; is unable, unwilling, or
fails to participate in available services or treatment for themselves or the child; or
fails to successfully and substantially complete available services or treatment for
themselves or the c hild.
[ ] Placement of the child in the [ ] mother’s [ ] father’s home is contingent upon
___________________________ (name of caregiver) engaging in and
completing additional services as listed in section 3.20 to ensure the safety of the
child [ ] prior to [ ] during the trial placement of the child in the home:
If your child is placed in your care, you have an ongoing duty to notify DCYF of all
persons who reside in the home or who may act as a caregiver for the child as long
as the court retains jurisdiction of this matter or DCYF is providing or monitoring
services to you or any caregiver of the child .
3.4 [ ] The child shall be in the custody, control, and care of:
[ ] a relative, ______________________________________ (name(s)), without
supervision of this placement by DCYF.
[ ] an other suitable person: ______________________________ (name(s)),
without supervision of this placement by DCYF.
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General
3.5 DCYF having custody of the child shall have full power to authorize and provide all necessary,
routine, and emergency medical, dental, or psychological care as recommended by the child's
treating doctor or psychologist, subject to revie w by the court, as needed.
3.6 All service providers shall make all records and all reports available to DCYF, the parent’s attorney,
and the guardian ad litem or attorney for the child. Parents shall sign releases of information and
allow all service pro viders to make all records available to DCYF and the guardian ad litem or
attorney for the child. Such information shall be provided immediately upon request. All
information, reports, records, etc., relating to the provision of, participation in, or par ties’ interaction
with services ordered by the court or offered by DCYF shall be subject to disclosure in open court
unless specifically prohibited by state or federal law or regulation.
3.7 The report of DCYF for the next review hearing shall be submitted to the court and to the parties at
least ten (10) days prior to the hearing.
3.8 [ ] A petition seeking termination of the parent -child relationship between the child's
[ ] mother [ ] father and the child shall b e filed by DCYF not later than
________________________________ (date).
Services
Any evaluation ordered by the court must comply with RCW 13.34.370.
3.9 [ ] Services for the mother are:
[ ] as set forth in the attached serv ice plan.
[ ] as follows:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
______________________ ________________________________________.
3.10 [ ] Services for the father(s) are:
[ ] as set forth in the attached service plan.
[ ] as follows:
___________________________________________________________ ____
_______________________________________________________________
_______________________________________________________________
______________________________________________________________.
3.11 [ ] Additional services for the [ ] mother [ ] father shall be initiated or completed are:
[ ] as set forth in the attached service plan.
[ ] as follows:
_______________________________________________________________
______________ _________________________________________________
_______________________________________________________________
______________________________________________________________.
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3.12 [ ] Services for the child(ren) are:
[ ] as set forth in the attached service plan.
[ ] as follows:
__________________________________________________________________
__________________________________________________________________
____________________________________________ ______________________
__________________________________________________________________
_________________________________________________________________.
[ ] SAY evaluation, and the child was notified that he/she may request an attorney.
[ ] The child is 12 or older and [ ] agrees to the services [ ] was notified of the
services [ ] was notified that he/she may request an attorney.
3.13 [ ] Child’s educational liaison
[ ] (Name) ________________________ shall continue as the child’s educational
liaison.
[ ] (Name) ________________________ is removed as the educational liaison.
[ ] The court appoints (name) ______________ __________ to serve as the child’s
educational liaison to carry out the responsibilities described in RCW 13.34.046 .
The educational liaison must complete criminal background checks required by
DCYF.
Visitation
3.14 [ ] The specific visit ation plan between the child(ren) and mother shall be:
[ ] as set forth in the visitation attachment.
[ ] as follows:
_______________________________________________________________
_____________________________________ __________________________
_______________________________________________________________
______________________________________________________________.
[ ] Visitation between the mother and the child may be expanded upon agreement of
the p arties
3.15 [ ] The specific visitation plan between the child(ren) and father shall be:
[ ] as set forth in the visitation attachment.
[ ] as follows:
_____________________________________________________ __________
_______________________________________________________________
_______________________________________________________________
______________________________________________________________.
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[ ] Visitation between the father and t he child may be expanded upon agreement of
the parties
3.16 [ ] The specific plan for visitation or contact between the child and child’s siblings shall be:
[ ] as set forth in the visitation attachment.
[ ] as follows:
_______________________________________________________________
_______________________________________________________________
______________________________________________________________.
Child’s Indian Status
3.17 Any party who subse quently receives information that provides a reason to know the child is an
Indian child under 25 C.F.R. § 23.107 shall inform the court.
Other
3.18 Other:
___________________________________________________________________________
_____________________ ______________________________________________________.
Permanency Planning Order – Required at Permanency Planning Hearing
3.19 The permanency plan for the child is:
Primary: Alternative:
[ ] [ ] Return of the child to the home of the [ ] mother [ ] father
[ ] guardian or [ ] legal custodian;
[ ] [ ] Adoption;
[ ] [ ] Final non -parental custody order pursuant to Chapter 26.10 RCW or the
equivalent laws of another state or a federally recognized Indian tribe;
[ ] [ ] Title 13 Guardianship;
[ ] [ ] Long term [ ] relative or [ ] foster care, for children between 16 and 18
years of age, with a written agreement;
[ ] [ ] Responsible living skills program; and/or
[ ] [ ] Independent living for children 16 and older .
3.20 The court orders the following actions to be taken to move the case toward permanency:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________.
3.21 Release of Information :
All court -ordered service providers shall make all records and all reports available to DCYF,
attorney for DCYF, parent’s attorney, the guardian ad litem and attorney for the child. Parents
shall sign releases of information and allow all court -ordered service providers to make all records
available to DCYF and the guardian ad litem or attorney for the child. Such information shall be
provided imme diately upon request. All information, reports, records, etc., relating to the provision
of, participation in, or parties’ interaction with services ordered by the court or offered by DCYF
may be subject to disclosure in open court unless specifically pro hibited by state or federal law or
regulation.
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DCYF may continue to make reasonable efforts to locate and investigate an appropriate relative
or other suitable person who is available and willing to care for the child, and is authorized to
share informatio n about the child, as necessary, with potential relative or other suitable person
placement resources to determine their suitability and willingness as a placement for the child.
3.22 All parties shall appear at the next scheduled hearing (see page one).
Dated:
Judge/Commissioner
Presented by:
________________________________________
Signature
________________________________________
Print Name/Title W SBA No.
Notice : A petition for permanent termination of the parent -child relationship may be fil ed
if the child is placed out -of -home under an order of dependency . (RCW 13.34.180 .)
Copy Received; Approved for Entry; Notice of Presentation W aived:
Signature of Child [ ] Signature of Child’s Lawyer
Print Name W SBA No.
[ ] Signature of Mother [ ] Signature of Mother’s Lawyer
[ ] Pro Se, Advised of Right to Counsel
Print Name W SBA No.
[ ] Signature of Father [ ] Signature of Father’s Lawyer
[ ] Pro Se, Advised of Right to Counsel
Print Name W SBA No.
[ ] Signature of Guardian or Legal Custodian [ ] Signature of Guardian or Legal Custodian’s Lawyer
[ ] Pro Se, Advised of Right to Couns el
Print Name W SBA No.
[ ] Signature of Child’s GAL [ ] Signature of Lawyer for the Child’s GAL
Print Name Print Name W SBA No.
[ ] Signature of DCYF Representative [ ] Signature of DCYF Representative’s Lawyer
Print Name Print Name W SBA No.
First/Dep Review/Perm Pla. Hrg Or (FDPRHO, DPRHO, ORPP ) - Page 14 of 14
W PF JU 03.0500 ( 07 /201 9) - JuCR 3.9; RCW 13.34.046, .130, .136, .138, .145
[ ] Signature of Tribal Representative [ ] Signature
Print Name Print Name W SBA No.
Lawyer for
[If the mother, father, guardian, or other person sig ns without legal representation, the certification below
shall also be signed.]
Certification
I certify under penalty of perjury under the laws of the state of W ashington that I have read or been told
the contents of the Dependency Review Hearing Order/Per manency Planning Hearing and I agree that the
order is accurate and should be signed by the court.
_______________________________________ _____________________________________
Mother Date and Place of Signature
_______________________________________ ____ _________________________________
Father Date and Place of Signature
_______________________________________ _____________________________________
Child’s Guardian or Legal Custodian Date and Place of Signature
_______________________________________ _____ ________________________________
Other Date and Place of Signature
