Form 171 - 247 - Allocation Of Parental Responsibilities Evaluation Referral Order Page 2
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2The 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.
County and Case Number(s) of IDVA cases involving the parties: _____________________________________
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 604.10(c), 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 604.10(c), the report shall be furnished to all attorneys of record as required by
604.10(c).
4. Pursuant to 750 ILCS 5/606.5(e), 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 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).
Psychological 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 604.10 report on ________________________________ at ______ M.
Dated at Waukegan, Illinois this
Enter:
day of
, 20
JUDGE
Prepared by:
Name: ____________________________________ Pro Se
Address: __________________________________________
City: ______________________________ State: __________
Phone: ______________________Zip Code: _____________
ARDC #: __________________________________________
Fax: ______________________________________________
E-mail address: _____________________________________
171 – 247 (Rev 12/15)
Page 2 of 2
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