San Francisco — Consent by Non-Minor Dependent for Assignment of Court Appointed Special Advocate (CASA) and Authorization to Share Information

Source: https://sf.courts.ca.gov/system/files/casa-consent-nmd-casa-and-release-information.pdf

Rev. 12/2017

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, Sate Bar Number, and Address) FOR COURT USE ONLY

TELEPHONE NO:

EMAIL ADDRESS (Optional): Superior Court of California, County of San Francisco Juvenile Justice Center 375 Woodside Avenue, Room 101, San Francisco, CA 94127 Civic Center Courthouse 400 McAllister Street, Room 402, San Francisco, CA 94102 CASE NAME: PIN (if applicable): CONSENT BY NON-MINOR DEPENDENT (NMD) FOR PETITION NUMBER: ASSIGNMENT OF COURT APPOINTED SPECIAL ADVOCATE (CASA) AND AUTHORIZATION TO SHARE INFORMATION

1. I, _________________________________________________ (print), am a Non-Minor Dependent or Ward of the

San Francisco Unified Family Court (UFC). My date of birth is ______________________________.

2. I hereby give my permission for the San Francisco Court Appointed Special Advocate Program (SFCASA) to assign to

me a Court Appointed Special Advocate (CASA). 3. I grant my permission for SFCASA and the CASA named below to request, receive and review written and oral information related to me according to the specific information below. 4. I further recognize I may be required to sign additional consent documentation related to California’s Confidentiality of Medical Information Act, Cal. Civil Code §56 et seq. According to California Rules of Court, Rule 5.900(c), and California Welfare and Institutions Code §303(d): “Nothing in the Welfare and Institutions Code…abrogates any right the non-minor dependent, as a person who has attained 18 years of age, may have as an adult under California law.” See also California Welfare and Institutions Code §107(b).

☐ Superior Court of California, County of San Francisco, Juvenile Case File as defined by CRC, Rule 5.552* ☐ Human Services Agency-Family and Children’s Services ☐ Juvenile Probation Department ☐ Schools, as named:____________________________________________________________________ ☐ Medical/Dental Providers, as named: ______________________________________________________ ☐ Independent Living Skills Program, as named: _______________________________________________ ☐ Behavioral Health Providers, as named: ____________________________________________________ ☐ Regional Center Services Provider, as named: _______________________________________________

5. I agree to cooperate with my CASA by maintaining contact with them. I understand that I may revoke my permission

for this CASA assignment at any time by submitting a request for their removal in writing to either

NMDRequest@sfcasa.org, or, SFCASA, 2535 Mission Street, San Francisco, CA 94110, and that my CASA may resign or be removed from my case by either a judicial officer of the UFC or SFCASA at any time. The CASA will adhere to the rules of confidentiality. My attorney of record has explained this agreement to me. I enter into this agreement voluntarily and of my own free will. I understand this agreement.

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Date Non-Minor Dependent (NMD)

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Date Court Appointed Special Advocate (CASA)

The undersigned certifies that they are an attorney duly licensed to practice law in the State of California; that they are the attorney of record for the NMD in the above case; that they have advised the NMD with respect to this Consent and has explained to the NMD its legal effect and meaning of it; and that the NMD has acknowledged full and complete understanding of the Consent and its legal consequences.

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Date Attorney of Record for NON-Minor Dependent (NMD)

*SFCASA is unable to collaborate with a Non-Minor Dependent (NMD) if at a minimum the NMD does not consent to access of the “Juvenile Case File” as defined by CRC, Rule 5.552

Rev. 12/2017

SFCASA PROGRAM GRIEVANCE POLICY

EVERY EFFORT SHOULD BE MADE TO SOLVE PROBLEMS COOPERATIVELY AND INFORMALLY BEFORE PRESENTING THEM AS A FORMAL GRIEVANCE. WE ENCOURAGE ANYONE TO CONTACT THE SFCASA OFFICE AND ASK TO SPEAK WITH THE PROGRAM DIRECTOR (OR A MEMBER OF THE STAFF AUTHORIZED TO SPEAK ON THEIR BEHALF) TO DISCUSS ANY CONCERNS. SHOULD INFORMAL EFFORTS FAIL, THE FOLLOWING POLICY IS SET FORTH IN ORDER TO PROVIDE AN OUTLET FOR COMPLAINTS AND SYSTEMATIC MEANS TO RESOLVE GRIEVANCES.

IF THE GRIEVANCE CONCERNS A CASA VOLUNTEER OR STAFF MEMBER, PLEASE SEND A LETTER, ALONG WITH SUPPORTING DOCUMENTS TO: SFCASA EXECUTIVE DIRECTOR 2535 MISSION STREET SAN FRANCISCO, CA 94110

• ONCE RECEIVED THE MATTER SHALL BE ASSIGNED TO A STAFF MEMBER AS APPROPRIATE. THE EXECUTIVE DIRECTOR WILL HAVE FINAL SAY IN THE MATTER. • DOCUMENTATION OF ANY GRIEVANCE FILED AGAINST A VOLUNTEER SHALL BE RETAINED IN THE VOLUNTEER’S FILE.

IF THE GRIEVANCE PERTAINS TO THE EXECUTIVE DIRECTOR, PLEASE SEND A LETTER, ALONG WITH SUPPORTING DOCUMENTS TO: SFCASA BOARD PRESIDENT 2535 MISSION STREET SAN FRANCISCO, CA 94110

• ONCE RECEIVED THE MATTER SHALL BE REVIEWED BY THE BOARD PRESIDENT. THE BOARD PRESIDENT SHALL HAVE FINAL SAY IN THE MATTER.

*SFCASA is unable to collaborate with a Non-Minor Dependent (NMD) if at a minimum the NMD does not consent to access of the “Juvenile Case File” as defined by CRC, Rule 5.552