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Here is the text we could read:

JV-225

Your Child's Health and Education

Clerk stamps date here when form is filed.

To the social worker or probation officer: If the parent or guardian needs  
help completing this form, please help him or her. 
To the parent or guardian: Complete and sign this form. If you need more  
space to answer, attach one or more sheets of paper to this form and write  
“JV-225” at the top of each page. The information requested on this form is  
necessary to meet the medical, dental, mental health, educational, and 
developmental needs of your child. The court has directed you to provide 
your child’s medical, dental,  mental health, educational, and developmental 
information. The court has also directed you to provide your medical, dental, 
mental health, and educational information and, if you know, the same 
information about the other parent or guardian. If you need help, the social 
worker or probation officer will help you fill out this form.

Your name:
Your relationship to child:
Your home address:
City:
Your mailing address:
City:
Your telephone number:

Your child’s name: 
a. Your child’s date of birth: 
b.

Where was your child born?
City:

Child’s Health 

State:

Zip code:

State:

Country:

Fill in court name and street address:
Superior Court of California, County of

c.
d.

Hospital:
Your child’s birth weight:

State:

Zip code:

Case Number:

Clerk fills in case number when form is filed.

Yes

Does your child have any physical or mental health challenges?  
If yes, is your child receiving any assistance, services, or treatment for these problems? (Explain):
a.
b.
c.
d.
e.
f.

Allergies:
Injuries:
Diseases:
Disabilities:
Other:
Other:

No

Has your child ever been admitted to the hospital for care or treatment of any of the conditions in item      ?    

3

Yes

No

If yes, please explain:

Is your child taking any medication?    
If yes, please list each medication and explain why your child is taking it:
Medication and dosage   

Reason for taking medication   

Yes

No

Date begun  

1

2

3

4

5

Judicial Council of California, www.courts.ca.gov 
Revised January 1, 2014, Mandatory Form 
Welfare and Institutions Code, § 16010

Your Child's Health and Education

JV-225, Page 1 of 5

Case Number:

hild’s name:

When was your child last seen by a doctor?    
Date: 
Doctor’s name: 
Office address: 
Mailing address (if different):
Telephone number: 

When was your child last seen by a dentist?    
Date: 
Dentist’s name: 
Office address: 
Mailing address (if different): 
Telephone number: 

List the names of all doctors, nurses, dentists, hospitals, clinics, and other health-care providers and healers, 
other than those listed in 6 and 7, who have seen your child within the past two years:  
Name 

Address (city, state, zip code)

Date of last visit 

Reason for visit 

What doctor, nurse, dentist, hospital, clinic, or other health-care provider has health records regarding your child?

Medical records: 
Dental records: 
Mental health records: 

a.
b.
c.
d. Other:

10

When was your child’s eyesight last tested?

Date of examination:
Who examined your child’s sight?
Address (include city, state, zip code):
Telephone number: 

Does your child wear glasses or contact lenses?

Yes

No

Does your child wear a hearing aid?

Yes

No

Is your child covered by an insurance policy?
a.  Medical 
b.  Dental  
c.  Vision 

Yes  
Yes  
Yes  

No 
No 
No 

(If yes, specify insurance policy):
(If yes, specify insurance policy):
(If yes, specify insurance policy):

6C

7

8

9

11

12

13

Child’s Education

14

When your child was living with you, what school did your child attend?

Name of school:
Address (include city, state, zip code):
a.
b.

Is your child still allowed and able to attend this school? 
If no, did you agree to give up your child’s right to remain at this school?

Yes

No

Yes

No

Revised January 1, 2014

Your Child's Health and Education

JV-225, Page 2 of 5

Child’s name:

14

c.

When your child was living with you, was your child receiving, or had your child received, any assistance 
or help at school or any assessments, evaluations, services, or accommodations to help your child with any 
physical, mental, or learning-related disabilities or other special educational needs? 
(1)

If yes, what assessments, evaluations, services, or accommodations was your child receiving?

Yes

No

Case Number:

(2)

Who gave your child these educational or developmental services?

d.

Has your child ever been referred to a regional center for developmental services?
If yes, list the name and location of the regional center and the date of the referral.

Yes

No

e.

If applicable, do you have a copy of your child’s individualized education program (IEP), section 504 plan,  
individualized family service plan (IFSP), individual program plan (IPP), or quality assurance assessment? 

What language did your child first learn to speak?

What is his or her primary language? 
What language do you most often use when speaking to your child?

Has your child ever been identified as limited English proficient or as an English Language Learner by a school?

Has your child ever been enrolled in a specialized program to learn English?

Yes

No

15

List all other schools or day care facilities your child has attended:  

Yes

No

Yes

No

f.

g.
h.

i.

j.

School (name, city, state):
School (name, city, state):
School (name, city, state):
School (name, city, state):

Dates of attendance:
Dates of attendance:
Dates of attendance:
Dates of attendance:

16

a.

What grade is your child in? 

b.

Does he or she have any special needs?   
If yes, please describe:

Yes

No

c.

If your child is three years old or younger, do you believe that your child might have motor, developmental,  
or other delays? 
If yes, explain why:

Yes

No

What assessments, evaluations, services, treatment, or accommodations do you believe your child needs for the 
delay?

Revised January 1, 2014

Your Child's Health and Education

JV-225, Page 3 of 5

Child’s name:

Case Number:

16

d.

Do you believe your child might have a disability?  
If yes, please describe:

Yes

No

What assessments, evaluations, services, treatment, or accommodations do you believe your child needs for the 
disability?

17

a.

Has your right to make educational decisions for your child been limited? 
If yes, who has the right to make educational decisions for your child?

Yes

No

b.

Has your right to make developmental-services decisions for your child been limited? 
If yes, who has the right to make developmental-services decisions for your child?

Yes
No
same as 17a. 

Name:
Relationship to child:

Name:
Relationship to child:

Biological Parent’s Health and Education (State law requires you to provide this information about yourself. If 
you do not want to provide this information, please talk to your attorney.)

18

a.

When were you last seen by a doctor and dentist?
(1) 
What medical problems run in your family? 

(2) 

Do you have medical problems or disabilities? 
If yes, please describe: 

Yes

No

(3)

What medications do you take? 
Medication           

Reason for taking medications

b.

What is your educational history?

(1)  School last attended (name, city, state):
(2)  Last grade completed:

19

a.

If you know, provide the following information about your child’s other biological parent:
(1)  Name of other parent:

Revised January 1, 2014

Your Child's Health and Education

JV-225, Page 4 of 5

Child’s name:

Case Number:

19

a.

(2) 

Other parent’s medical problems and disabilities 
(Please include physical, mental, developmental, and learning problems):

(3) 

My child’s other parent takes the following medications:
Medication           

Reason for taking medication

(4)  The following medical problems run in the family of my child’s other parent:

b.

 My child’s other parent has the following educational history:
(1)  School last attended:

(2)  Last grade completed:

I declare that the information on this form is true and correct to the best of my knowledge. 

Type or print parent’s/guardian’s name

Parent/guardian signs here

Type or print social worker’s name

Social worker signs here

Date:

Date:

Date:

}

}

}

Type or print probation officer’s name

Probation officer signs here

Revised January 1, 2014

Your Child's Health and Education

JV-225, Page 5 of 5

For your protection and privacy, please press the Clear 
This Form button after you have printed the form.

Your Child's Health and Education

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 5
Fields(s): 139
Average fields per page: 27
Reading Level: Grade 6
LIST Grouping(s): HE-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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topmost_subform_page_med_tf__2 was topmostSubform[0].Page1[0].Med_tf[1] (0.45 conf)
topmost_subform_page_med_tf__3 was topmostSubform[0].Page1[0].Med_tf[2] (0.45 conf)
topmost_subform_page_area_date_tf__1 was topmostSubform[0].Page1[0].#area[1].Date_tf[0] (0.40 conf)
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topmost_subform_page_area_date_tf__3 was topmostSubform[0].Page1[0].#area[1].Date_tf[2] (0.40 conf)
topmost_subform_page_area_reason_tf__1 was topmostSubform[0].Page1[0].#area[2].Reason_tf[0] (0.40 conf)
topmost_subform_page_area_reason_tf__2 was topmostSubform[0].Page1[0].#area[2].Reason_tf[1] (0.40 conf)
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topmost_page_text_field__11 was topmostSubform[0].Page4[0].TextField2[1] (0.36 conf)
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topmost_page_text_field__13 was topmostSubform[0].Page4[0].TextField2[3] (0.36 conf)
topmost_page_text_field__14 was topmostSubform[0].Page4[0].TextField2[4] (0.36 conf)
topmost_page_text_field__15 was topmostSubform[0].Page4[0].TextField2[5] (0.36 conf)
topmost_subform_page_p_e_header_grp_case_number_ft__3 was topmostSubform[0].Page4[0].PE_P2Header\.grp[0].CaseNumber_ft[0] (0.45 conf)
topmost_page_child_name_ft__3 was topmostSubform[0].Page4[0].ChildName_ft[0] (0.36 conf)
topmost_subform_page__58 was topmostSubform[0].Page5[0].T50[0] (0.38 conf)
topmost_subform_page__59 was topmostSubform[0].Page5[0].T51[0] (0.38 conf)
topmost_subform_page_specify_tf__1 was topmostSubform[0].Page5[0].OtherSpecify_tf[0] (0.40 conf)
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topmost_page_text_field__17 was topmostSubform[0].Page5[0].TextField2[1] (0.36 conf)
topmost_page_text_field__18 was topmostSubform[0].Page5[0].TextField2[2] (0.36 conf)
topmost_page_text_field__19 was topmostSubform[0].Page5[0].TextField2[3] (0.36 conf)
topmost_page_text_field__20 was topmostSubform[0].Page5[0].TextField2[4] (0.36 conf)
topmost_page_text_field__21 was topmostSubform[0].Page5[0].TextField2[5] (0.36 conf)
topmost_subform_page_specify_tf__2 was topmostSubform[0].Page5[0].OtherSpecify_tf[1] (0.40 conf)
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topmost_subform_page_p_e_header_grp_case_number_ft__4 was topmostSubform[0].Page5[0].PE_P2Header\.grp[0].CaseNumber_ft[0] (0.45 conf)
topmost_page_child_name_ft__4 was topmostSubform[0].Page5[0].ChildName_ft[0] (0.36 conf)
topmost_multi_line_field_text__1 was topmostSubform[0].Page5[0].MultiLine_Field[0].TextField2[6] (0.44 conf)
topmost_subform_page__61 was topmostSubform[0].Page5[0].T56[1] (0.38 conf)
topmost_multi_line_field_text__2 was topmostSubform[0].Page5[0].MultiLine_Field[1].TextField2[7] (0.44 conf)
topmost_subform_page__62 was topmostSubform[0].Page5[0].T56[2] (0.38 conf)
topmost_multi_line_field_text__3 was topmostSubform[0].Page5[0].MultiLine_Field[2].TextField2[8] (0.44 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

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