Fill and Sign the Mental Health Procedures Maryland Courts Form

PT For Rev of Out-of-Home Placement (PTDDP) - Page 1 of 3WPF JU 12.0100 (07/2011) - JuCR 3.3; RCW 13.34.270(1),(2); RCW 74.13.350SUPERIOR COURT OF WASHINGTONCOUNTY OF _______________________ JUVENILE COURT In Re the Welfare of:D.O.B.: No:Petition for Review of Out-of-Home Placement(PTDDP) I. Basis I represent to the court the following:1.1 Child in Out-of-Home Placement: [ ] male [ ] femaleNameDate of BirthHome Address1.2 Identification of the Parents or Legal Guardians who Agreed to the Child’s Placement in Out-of- Home Care:[ ] Mother[ ] Father [ ] presumed [ ] allegedName12Date of BirthMarital status[ ] single [ ] married [ ] other [ ] single [ ] married [ ] otherDriver’s License or Identicard (# and State)Home Address[ ] Father [ ] presumed [ ] alleged[ ] Custodian/Legal GuardianName34Date of BirthMarital status[ ] single [ ] married [ ] otherDriver’s License or Identicard (# and State)Home AddressFOR OFFICIAL USE ONLY Juv. Ref. No: __________________________ PT For Rev of Out-of-Home Placement (PTDDP) - Page 2 of 3WPF JU 12.0100 (07/2011) - JuCR 3.3; RCW 13.34.270(1),(2); RCW 74.13.3501.2 Identification of Parents who are not Parties to the Out-of-Home Placement Agreement:[ ] Mother[ ] Father [ ] presumed [ ] allegedName12Date of BirthMarital status[ ] single [ ] married [ ] other [ ] single [ ] married [ ] otherDriver’s License or Identicard (# and State)Home Address 1.4 Jurisdiction: The child is located or is residing within this county. The child has a developmental disability as defined in RCW 71A.10.020.The child has been placed in out-of-home care pursuant to RCW 74.13.350. 1.5 Child’s Indian status:The petitioner has made the following efforts and cannot determine whether the child is an Indian child as defined Laws of 2011, ch. 309, §4: . [ ] Based upon the following, the child is not an Indian child as defined in Laws of 2011, ch. 309, §4, and the federal and Washington State Indian Child Welfare Acts do not apply to these proceedings: . [ ] Based upon the following, the child is an Indian child as defined in Laws of 2011, ch. 309, §4 and the federal and Washington State Indian Child Welfare Acts do apply to these proceedings: . [ ] The petitioner has made the following preliminary efforts to provide notice of these proceedings to all tribes to which the petitioner knows or has reason to know the child may be a member or eligible for membership: . 1.6 Parents Unable to Assume Custody of the Child: [ ] The Department of Social and Health Services made reasonable efforts and was unable to ascertain the identity, location and custodial status of any parent who is not a party to the placement agreement.[ ] The parents listed in paragraph 1.2, whose custodial status is , cannot assume custody of the child because: PT For Rev of Out-of-Home Placement (PTDDP) - Page 3 of 3WPF JU 12.0100 (07/2011) - JuCR 3.3; RCW 13.34.270(1),(2); RCW 74.13.350 . II. Relief Requested I request that the court review the child’s placement, make a determination that continued Out-of-Home Placement is in the best interest of the child, and take other necessary action as provided in RCW 13.34.270.Dated: __________________________ _____________________________________________ Petitioner_____________________________________________Type or Print Name/Title WSBA No. III. Certification I certify under penalty of perjury under the laws of the state of Washington that the representations in the foregoing Petition for Review of Out-Of-Home Placement are true and correct.Signed at _________________________ (city), Washington on _______________________ (date). _____________________________________________Signature [ ] I have examined the petition and have determined that it is reasonably justifiable.Probation Officer: _____________________________________________Signature_____________________________________________Type or Print Name