Fill and Sign the Washington Child Services Form

Superior Court of Washington County of _______________________ Juvenile Court In the Interest of: D.O.B.: No : Child in Need of Services (CHINS) Petition (PTCIN) I. Basis I represent to the court the following: 1.1 Identification of the parents or legal custodians and guardians: Name 1 2 Date of Birth Driver’s License or Identicard (# and State) Home Address The parents’ marital status is: 1.2 Child alleged to be in need of services: Name Date of Birth Sex Home Address 1.3 Child’s Indian status: CHINS Petition (PTCIN) - Page 1 of 3 WPF JU 05.0100 (07/2018) - RCW 13.32A.140, .150 FOR OFFICIAL USE ONLY Juv. Ref. No.: _____________________________ The petitioner knows or has reason to know that an Indian child is involved. The Department of Children, Youth, and Families is the petitioner. The Federal and the Washington State Indian Child Welfare Acts apply to this proceeding. 1.4 Petitioner is: the child. the parent, who is a resident of __________________________ County. the Department of Children, Youth, and Families. 1.5 The child is in need of services, as defined in RCW 13.32A.030(5), in that: a. the child is beyond the control of his/her parent(s) such that the child’s behavior endangers the health, safety, or welfare of the child or other person; b. the child has been reported as absent without consent for at least 24 consecutive hours on two or more separate occasions from the parent’s home, a crisis residential center, an out-of-home placement, or a court-ordered placement; and has exhibited a serious substance abuse problem; or has exhibited behaviors that create a risk of serious harm to the health, safety, or welfare of the child or any other person; or c. the child is in need of necessary services (including food, shelter, health care, clothing, education, or services designed to maintain or reunite the family); and the child lacks access to, or has declined to utilize these services; and the child’s parents have evidenced continuing but unsuccessful efforts to maintain the family structure or are unable or unwilling to continue efforts to maintain the family structure. d. the child is a “sexually exploited child.” e. the requirements of RCW 13.32A.140 are met. 1.6 The allegation that the child is in need of services is based on the following facts: . 1.7 A serious conflict exists between the parent and child. a. The petitioner has made a reasonable effort to resolve the conflict. CHINS Petition (PTCIN) - Page 2 of 3 WPF JU 05.0100 (07/2018) - RCW 13.32A.140, .150 b. Reasonable efforts have been made to prevent or eliminate the need for removal of the child from the child’s home and to make it possible for the child to return home. c. A suitable out-of-home placement resource is available. II. Relief Requested I request that the court order out-of-home placement of the child. III. Certification I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Dated at ___________________________________, Washington on ____________________________. (Place) (Date) Address Signature _____________________________________________ Type or Print Name _____________________________________________ Telephone CHINS Petition (PTCIN) - Page 3 of 3 WPF JU 05.0100 (07/2018) - RCW 13.32A.140, .150