JV-214

Request for Hearing on Waiver of 
Presumptive Transfer 

Clerk stamps date here when form is filed.

Person or agency responsible for making mental health decisions 
on behalf of the child or nonminor

Fill in court name and street address:

Superior Court of California, County of

Use this form to request a court hearing to challenge the decision made by 
the placing agency on the request for waiver of presumptive transfer of the 
responsibility for specialty mental health services. (Read form JV-214-
INFO, Instructions for Requesting a Hearing to Review Waiver of 
Presumptive Transfer of Specialty Mental Health Services).

1 My relationship to the child or nonminor:

Self

Other:

The child’s or nonminor’s attorney

Parent or legal guardian

2

My contact information (if confidential, use form JV-287):
a.

Name:

Street address:

City/State/Zip:

Telephone number:

E-mail address:

Fill in child's name and date of birth:

Child's/Nonminor's Name:

Date of Birth:

Case Number:

Court fills in case number when form is filed.

The child or nonminor is placed or will be placed in a county that is not the county of original jurisdiction (home 
county). The out-of-county placement is in (name county):                                                     county.

A request was made to the agency making this placement that the responsibility for providing specialty mental 
health services to the child or nonminor shoud be waived and not transferred to the new county. That request was 
made on (date)                                                   by (name):                                                        .

On (date):                                               , the agency making the placement informed me:

That an exception or waiver applies to the rule that the responsibility for providing specialty mental health 
services be transferred to the county where the child or nonminor lives or will live, and the responsibility 
should remain with the child’s or nonminor’s home county.

That the request for the waiver of the responsibility for the child’s or nonminor’s specialty mental health 
services is denied and the responsibility for those services should be transferred to the new county of 
residence.

I disagree with the agency’s decision about transferring the responsibility for specialty mental health services to the 
new county, as follows:
a.

The responsibility for the child’s or nonminor’s specialty mental health services should transfer to the county 
where the child or nonminor lives or will live.

Judicial Council of California, www.courts.ca.gov 
New September 1, 2018, Mandatory Form 
Welfare and Institutions Code, § 14717.1 

Request for Hearing on 
Waiver of Presumptive Transfer

JV-214, Page 1 of 2

a.

b.

c.

d.

e.

b.

c.

d.

e.

a.

b.

3

4

5

6

Child's/Nonminor's Name:

Case Number:

6

b.

The following exception to presumptive transfer should be applied and the responsibility for providing or 
arranging specialty mental health services should remain with the child’s or nonminor’s home county:

(1)

(2)
(3)

(4)

The transfer would disrupt continuity of care or delay access to services provided to the child or 
nonminor.
The transfer would interfere with family reunification efforts documented in the individual case plan.
The child’s or nonminor’s placement in a county other than the county of original jurisdiction is 
expected to last less than six months.
The child’s or nonminor’s residence is within 30 minutes of travel time to his or her established 
specialty mental health care provider in the county of original jurisdiction.

7

My request in  6   is in the child’s or nonminor’s best interests because (explain the best interest to the child or 
nonminor and provide a brief factual description of the exception to presumptive transfer selected in item 6b):

I am requesting that the court grant a hearing on this matter.

On (date):                                            I informed the placing agency that I was requesting a court hearing to review 
the decision on presumptive transfer by providing the placing agency with a copy of this form.

8

9

Date:

Type or print your name

Sign your name

New September 1, 2018

Request for Hearing on 
Waiver of Presumptive Transfer

JV-214, Page 2 of 2