JV-235

Placing Agency's Request for 
Review of Placement in Short-Term 
Residential Therapeutic Program or 
Community Treatment Facility

Clerk stamps date here when form is filed.

1 Agency requesting review:

Name and title of person filing the form:

2

The child or nonminor dependent was placed at the 
following short-term residential therapeutic program or 
community treatment facility:

The placement is confidential; the name and address of the 
placement are submitted separately on form JV-287.

Address:

Phone:

Name:

Address:

on (date):

Fill in court name and street address:

Superior Court of California, County of

Fill in child's/nonminor's name and date of birth:

Child's/Nonminor's name:

Child's/Nonminor's date of birth:

The agency listed in 1 requests that the court set a hearing under
Welf. & Inst. Code, § 361.22 or § 727.12 to review the placement of 
the child or nonminor dependent in the short-term residential 
therapeutic program or community treatment facility.

Court fills in case number when form is filed.

Case Number:

To:
•  Parent or guardian;
•  Child or nonminor dependent; and
•  Child's Indian tribe or Indian custodian, in the case of an Indian child
There will be a court hearing scheduled within 45 days of the date listed in item 2 to review the placement of the 
child in the facility mentioned above. The court will let you know when the hearing will be. You will have the 
option to attend the hearing if you choose. Before the hearing, you will receive a report from the social worker or 
probation officer that will explain why the placement was made and how it serves the needs of the child or 
nonminor dependent.

If you do not agree with the placement and want to let the judge know you don't agree, work with your lawyer if 
you have one, about how to let the judge know that you do not agree. To inform the judge of your disagreement 
with the placement before the hearing, you must use form JV-236, Input on Placement in Short-Term Residential 
Therapeutic Program or Community Treatment Facility. You must do so quickly because you only have five court 
days after you receive the report to file the form. The court might cancel the hearing and approve the placement if 
no one objects to the placement. The social worker or probation officer will inform you that the court may consider 
canceling the hearing by sending you form JV-240, Notice of Request for Approval of Short-Term Residential 
Therapeutic Program or Community Treatment Facility Without a Hearing.

3

4

Date:

Type or print your name

Sign your name

Judicial Council of California, 
Rev. January 1, 2023, Mandatory Form 
Welfare and Institutions Code, §§ 361.22, 727.12 
California Rules of Court, rule 5.618

Placing Agency's Request for Review of Placement 
in Short-Term Residential Therapeutic Program or 
Community Treatment Facility

JV-235, Page 1 of 1