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JDF 453 R3/18 AFFIDAVIT OF RELINQUISHMENT COUNSELING Page 1 of 2District Court Denver Juvenile Court_____________________County, ColoradoCourt Address:In the Matter of the Petition of:__________________________________________________ And____________________________________________Petitioner(s)For the Relinquishment of a Child,_______________________________________________________ (child’s name) COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail:FAX Number: Atty. Reg. #:Case Number:Division Courtroom AFFIDAVIT OF RELINQUISHMENT COUNSELING I, o f C ounty Departm ent of Socia l S erv ic e s/C hild P la ce m ent A ge ncy, s ta te t h at I p ro vid ed c o unse lin g t o on t h e f o llo w in g d ate s _ _____ _________________________ c o nce rn in g t h e P etit io ner’s P etit io n f o r R elin quis h m ent. 1 . The n atu re a nd e xte nt o f c o unse lin g in clu ded t h e f o llo w in g:I nfo rm atio n to P etit io ner co nce rn in g th e p erm anence o f th e d ecis io n to re lin quis h a nd th e im pact o f th e de cis io n o n P etit io ner n ow a nd in t h e f u tu re .I nfo rm atio n w as o bta in ed fr o m P etit io ner a bout th e c o m ple te m edic a l a nd s o cia l h is to rie s o f b oth o f th e c h ild ’s pa re nts .I f P etit io ner w as p re gnant, th e P etit io ner w as re fe rre d fo r m edic a l c a re a nd a d ete rm in atio n o f e lig ib ilit y fo r me dic a l a ssis ta n ce .I nfo rm atio n a bout a lt e rn ativ e s to re lin quis h m ent a nd a re fe rra l to p riv a te a nd p ublic re so urc e s th at m ay m eet th e p are nts ’ n eeds.I nfo rm atio n a b out r e lin quis h m ent s e rv ic e s n ece ssa ry to p ro te ct th e in te re sts a nd w elf a re o f th e c h ild if th e c h ild wa s b orn in a s ta te in stit u tio n.I nfo rm atio n th at if P etit io ne r a pplie s fo r p ublic a ssis ta nce fo r P etit io ner o r th e c h ild , P etit io ner m ust c o opera te wit h t h e C hild S upport E nfo rc e m ent U nit f o r t h e e sta blis h m ent o f a c h ild s u pport o rd er.T hat a ll in fo rm atio n, e xce pt n on-id entif y in g in fo rm atio n a s d efin ed in § 19-1 -1 03(8 0), C .R .S ., o bta in ed in th e co urs e o f re lin quis h m ent c o un se lin g, is c o nfid entia l, u nle ss th e p are nt p ro vid es w rit te n in fo rm atio n o r a c o urt or d ers a r e le ase o f in fo rm atio n .O th er c o unse lin g p ro vid ed: JDF 453 R3/18 AFFIDAVIT OF RELINQUISHMENT COUNSELING Page 2 of 22. The A ffia nt h as p re pare d a re port a s “E xh ib it A ” th at o utlin es th e p ro ce ss o f re lin quis h m ent c o unse lin g in m ore de ta il. By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct.Executed on the ______ day of ________________, _______, at ______________________________________ (date) (month) (year) (city or other location, and state OR country___________________________________ ______________________________________ (printed name of Counselor) Signature of Counselor