For Referral Questions:

Vivian Lambert, CAP Supervisor

PH: 408-573-5604

Scan/Email:

Non-Minor Dependent Agreement

**Please attach a copy of the original jurisdictional report, latest court report, most recent IEP or 504 Plan.

First Name: ______Last Name: ______

Petition No: ______Date Petition Filed: ______

Date of Birth: ______Gender: _____ Primary Language: ______Ethnicity: ______

Referred to CASV Date: ______Referred By: ______

NMD’s Current Placement

Start Date: ______# of placements before CASA referral: _____

Facility Name: ______ContactPerson: ______

Address: ______Facility Type: ______

City/State/Zip: ______Email Address: ______

Phone: ______Fax: ______

Interested in High School or College Assistance?: ______

School Name/grade: ______Received HS Diploma GED/test

Are You Currently Employed? ______If so, where?: ______

Pay per Hour: ______Start Date: ______End Date: ______

Below are areas where a CASA could help support you

Reason(s) for Support/Advocacy (please check all that applicable):

Lack of Family SupportTrust & Relationship BuildingCultural/Community Events

Health or Physical DisabilityTeen PregnancyExtracurricular Activities

Mental Health IssuesEducational SupportHealthy Choices & Behaviors

Gang AffiliationIncarcerated Parent(s)Self-Esteem Building

Long Term Foster CareLGBTQ SupportDevelopmentalMilestones/Independent Living Skills

How could this NMD benefit from a CASA? (Add an attachment for further details)

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Professionals assigned to child:

Social Worker: ______Email: ______Phone: ______

LACY Attorney______Email: ______Phone: ______

Probation Officer:______Email: ______Phone: ______

Therapist:______Email: ______Phone: ______

ILP Case Manager: ______Email: ______Phone: ______

Judge: ______Next Hearing Date: ______Department: ______

If a non-minor requests a CASA, the non-minor dependent will be placed on the waitlist, but there is no guarantee that a CASA will be assigned.

If a CASA is assigned, the following are expected of the relationship between the non-minor dependent and the CASA.

The non-minor dependent will:

  • Maintain at least monthly contact with the CASA;
  • Adhere to the terms of the Court Order;
  • Contact the Advocate’s Supervisor if the non-minor dependent wants to modify the terms of the Court Order.

The CASA will:

  • Maintain at least monthly contact with the non-minor dependent;
  • Adhere to the terms of the Court Order;
  • Assist with any education and residential issues as requested;
  • Assist with learning independent living skills (i.e. obtaining employment, financial aid), but cannot co-sign any documents for the non-minor dependent;
  • Not allow non-minor dependent to go to the CASA’s home or the homes of the CASA’s family or friends;
  • Keep the non-minor dependent’s information confidential unless given explicit permission by the non-minor dependent.

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Signature of Non-Minor DependentDate

Child Advocates of Silicon Valley 509 Valley Way, Bldg. #2 Milpitas, CA 95035 Main: 408-416-0400

Rev. 01/2017