SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
Your name: ___________________________________
Your address: _________________________________
_____________________________________________
IN PRO PER
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
In re the Matter/Marriage of: )
) CASE NO.:
)
) FCS NO.:
, )
Petitioner ) EX PARTE REQUEST TO
) APPOINT PSYCHOLOGICAL
and ) EVALUATOR AND FOR COURT
) TO PAY EVALUATOR’S FEES;
) DECLARATION; ORDER
, )
Respondent ) DEPARTMENT _____
PETITIONER / RESPONDENT (circle one), ________________________________, requests that the Court appoint a psychological evaluator for PETITIONER / RESPONDENT (circle one), _________________________________, and order that the Superior Court, County of Santa Clara, pay the evaluator’s fees, up to $750.00.
DECLARATION OF (your name)______________________________:
The Court previously ordered that I undergo psychological testing (order filed (date): _______________). Since then I have contacted several doctors and learned that their fees are at least $_____________. Based on my income I can’t pay that amount (Income & Expense Declaration attached). I obtained a list of “Mental Health Professionals Completing DV Training” and contacted many of the professionals to see if any of them would be willing to take my case at a lower cost. Dr. _______________________ has agreed to test me for $750.00. I am asking that the Court appoint Dr. ______________ to perform the psychological evaluation on me and that the Court pay the $750.00 fee because I can’t afford it.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
THE COURT FINDS THAT:
1) ________________________ is a psychological evaluator who is competent to perform psychological testing on PETITIONER / RESPONDENT (circle one), (name)___________________________, to determine PETITIONER’s / RESPONDENT’s (circle one) ability to care for the parties’ minor child(ren).
2) PETITIONER / RESPONDENT (circle one), (name)________________________, is unable to pay any of the expense for the psychological evaluation.
3) The Superior Court, County of Santa Clara should pay the expense for the psychological evaluation which should not exceed $750.00.
GOOD CAUSE APPEARING, IT IS ORDERED THAT:
1) (Name of Evaluator) _____________
located at (address) _
is appointed by the Court to perform psychological testing on
PETITIONER / RESPONDENT (circle one), (name)
.
The purpose of said testing is to assist the Court in determining the
PETITIONER / RESPONDENT’s (circle one), (name)
ability to care for the minor children.
The court orders the Superior Court, County of Santa Clara, to pay $750.00 for
said testing due to the inability of PETITIONER / RESPONDENT (circle one),
(name)__________________________________ to pay all of the cost.
(4) The total cost for this testing shall not exceed $ 750.00.
Dated: _________________________________
JUDGE OF THE SUPERIOR COURT
/ / /
/ / /
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