Use this template/form to file for child custody in the state of Illinois
Text version of this Form
———————– Page 1———————–
IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT
LAKE COUNTY, ILLINOIS
)
)
)
Petitioner, ) Gen No.
vs. )
) Previous or current OPs involving either of the parties:
) OP Case No: County:
Respondent. ) OP Case No: County:
CUSTODY/VISITATION
EVALUATION REFERRAL ORDER
On motion of: Petitioner Respondent Attorney for Minor Child Child Rep Court
It is hereby ordered that this matter is referred to:
Evaluator/Counselor:
Name
Address
Telephone Fax
Pursuant to:
750 ILCS 5/604(b), to provide the court with professional advice on issues relating to the best interests and
wishes of the child(ren) who is/are the subject of custody proceedings.
750 ILCS 5/604.5 for an evaluation concerning the best interests of the child(ren) as it relates to custody, visitation
or removal. The time and place of the evaluation: at .
(Time) (Place)
750 ILCS 5/605, to conduct an investigation concerning custodial arrangements for a child who is the subject of
custody proceedings.
Party A Name: Telephone: ( )
Address:
(Street/City/State/ZIP)
Attorney for Party: Telephone: ( )
Address:
(Street/City/State/ZIP)
Party B Name: Telephone: ( )
Address:
(Street/City/State/ZIP)
Attorney for Party: Telephone: ( )
Address:
(Street/City/State/ZIP)
GAL/AFC/CR Name: Telephone:( )
Address:
(Street/City/State/ZIP)
Scope of appointment:
Custody – Original Modification
Visitation – Original Modification Abuse
Removal Other conditions of appointment
The parties represent:
No orders of protection have ever been entered involving the parties to this case, or
The parties are, or have been in the past, involved in a proceeding(s) under the Illinois Domestic Violence Act.
A current order of protection prohibits one of the parties from having contact with the other party.
Page 1 of 2 171-247 Rev 07/08
———————– Page 2———————–
Additional Matters:
1. The parties are ordered to contact the appointee within two (2) business days to schedule the first appointment.
2. Except if the referral is pursuant to 604.5, the appointee shall provide a written report to the court and send copies
to the attorneys for the parties and to any pro se party three (3) days prior to the date set for presentation of the
report.
3. If the referral is pursuant to 604.5, the report shall be furnished to all attorneys of record as required by 604.5(d).
4. Pursuant to 750 ILCS 5/606(d), the final report of the appointee furnished to the court shall be kept sealed by the
Clerk of the Court unless otherwise ordered.
5. The provider may communicate freely with the child representative, attorney and/or the guardian ad litem for the
child(ren). Except to discuss the scheduling matters, the provider may not communicate with an attorney for a
party on an ex parte basis. Communications with attorneys on substantive matters must be by conference call or
in writing with a copy to each attorney.
6. Unless a proper written consent has first been obtained, an appointee may not obtain medical, psychiatric or other
expert information about any person investigated, except for information about a minor as provided in 750 ILCS
5/605 or 740 ILCS 110 et seq.
7. When served with a subpoena, an appointee shall be obligated to produce his or her file of underlying data
obtained in regard to this case as well as the names and addresses of all persons whom the appointee consulted.
However, unless a proper written consent specifically so authorizes, the appointee may not re-release
medical, psychiatric or other expert information obtained pursuant to an initial written consent.
8. Pursuant to the Mental Health and Developmental Disabilities Confidentiality Act 740 ILCS 110/3 (c),
psychological test materials whose disclosure would compromise the objectivity or fairness of the testing process
may not be disclosed to anyone, including the subject of the test, and is not subject to disclosure in any
administrative, judicial or legislative proceeding. However, the recipient may have all records relating to the test
disclosed to any psychologist designated by the recipient. Requests for such disclosure shall be in writing and
comply with the requirements of 740 ILCS 110/5(b).
Pyschological testing:
Neither party nor the child(ren) shall be required to submit to psychological testing nor shall they be referred to other
professionals for evaluation except as follows: .
Fee Allocation: The fees of the appointee shall be paid as follows:
Party A % Party B % County of Lake % (Limit on amount County will pay $ )
The matter is set for presentation of final 604(b) or 605 report on at M.
Dated at Waukegan, Illinois this day
of , 20
ENTER:
JUDGE
Prepared by:
Attorney’s Name: _
Address:
City: State:
Phone: Zip Code:
Fax:
ARDC:
Page 2 of 2 171-247 Rev 07/08