INSTRUCTIONS FOR COMPLETION OF AUTHORIZATION FORM

Purpose: You should use this form when you want DCYF to be able to disclose confidential information about you to another person (including
an attorney, a legislator, or a relative). You may give permission to disclose all confidential records DCYF has about you or you may limit your
permission to specific records or parts of the agency. This form will also permit DCYF to discuss your situation verbally with the person you
authorize.
Notice to Clients: Most client information DCYF has is confidential and will not be disclosed to others unless you grant permission or if
disclosure is allowed by law. After DCYF discloses your confidential information, please be aware that the recipient may not protect your records
under the same laws that apply to DCYF. DCYF cannot refuse you benefits if you do not sign this form to allow disclosures to DCYF unless your
authorization is needed to determine eligibility. For information on how DCYF health care components covered by HIPAA share protected health
information and your privacy rights, please consult the DCYF Notice of Privacy Practices at www.DCYF.wa.gov or ask the person who gave you
this form. You may get a copy of this form.
Use: You may fill out this form electronically or by hand. Use the tab key on a computer to move between fields. A separate form must be
completed for each person whose records are requested, including children. “You” refers to the subject of the records.
Parts of Form:
IDENTIFICATION OF SUBJECT OF RECORDS:
Name: Provide your full name or the name of the person whose records are requested if you are acting for someone else.
Date of birth: Please include this information needed to identify you from persons with similar names.
OPTIONAL INFORMATION to help locate records:
Former names: Include any other names that have been used when receiving benefits or services.
Client identification number: Provide any number that DCYF may have assigned.
Other identification number: Include any other identifier that could help locate DCYF records. Only provide a social security
number if necessary.
Date and location of services: Provide this information to help DCYF identify and locate the records you want disclosed.
PERSON RECEIVING RECORDS:
Identification: Please fill out this section as fully as possible so we can contact the person or organization who will have
access to your confidential information.
Reason for Disclosure: This information is required before DCYF can share drug and alcohol or mental health records. If you
do not fill in this field, DCYF will note the reason for disclosure as being at your request.
AUTHORIZATION:
Parts of DCYF: Please mark either the parts of DCYF you want to disclose records or mark the bottom box in this section if
you want to give access to any records DCYF has about you. Write in the name of program in “Other” if not in the list.
Information disclosed: Indicate what records that you want disclosed. You may allow disclosure of all or part of your DCYF
client or other confidential records. You may also limit disclosure to client records held only by the parts of the agency marked
in the section above, or to specific records listed on this form or on an attachment you sign. If there are any limitations on
what records you want disclosed, either list specific records or describe the limits, such as by date of services or type of
record.
Restricted records: If any of the records may include information about HIV/AIDS or STD testing or treatment, mental health
treatment, or drug and alcohol services, you must check each item to allow DCYF to disclose these records. You need to
complete a separate form to authorize disclosure of psychotherapy notes (45 CFR 164.508(b) (3) (ii)).
Validity: This form is valid to give access to information currently held by DCYF. Your permission expires 180 days after
signature or on any other date or event you provide. If you do not provide a date, the authorization will be valid for 180 days.
You may revoke the authority to release records in writing at any time but it will be too late to take back information already
produced.
Cost: The public records act in RCW 42.56.120 and WAC 388-01-080 allow DCYF to charge for copies of records plus
mailing costs. State hospitals and health care facilities may charge for patient records under Chapter 70.02 RCW.
SIGNATURES:
If you are the subject of the records, sign and also print or type your name below. Insert the date you signed plus your telephone or contact
number.
If you are signing for another person, indicate why you can do so on the last line and attach a copy of the court order or other document
giving you legal authority. Children must also sign to give permission to disclose their own confidential records if they are over the age of
consent (13 for mental health and drug and alcohol services; 14 for information about HIV/AIDS or other STDs; any age for birth control and
abortions; 18 for health or other records).
Witness or notary: A witness or notary may be needed to verify your identity if you do not submit this form in person or if a program requests
verification. This person should sign and print his or her name.
NOTICE TO DCYF: If these records contain HIV or STD information, DCYF must notify recipients that the information is confidential and that
they may not further disclose the records without a specific authorization as required by RCW 70.02.300. If DCYF sends copies of records
regarding drug or alcohol services under this authorization, DCYF must include the following statement when disclosing information as required
by 42 CFR 2.32:
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit
you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to
whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT
sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse
patient.
AUTHORIZATION Page 2 of 2
DCYF 17-063 (rev.01/2019) INT/EXT
 GUIDELINES FOR WORKING WITH THE GUARDIAN AD LITEM
(aka What to Expect and What is Expected of You)

Most, if not all, of the following information will be or has been provided to you during your initial interview with the guardian
ad litem. This set of guidelines is not intended to be an all inclusive list of information items you need to know, but rather is
designed to provide you with reminders of what you should expect from the guardian ad litem (GAL) and what is expected of
you during the GAL’s investigation.

1. Every person involved in the case as either a petitioner or a respondent is a “party” to the case. Family members,
spouses, case workers, and others who are neither petitioners or respondents are not parties. Lawyers for parties and
GALs who have been appointed for parties or for other children involved in the case are not parties but are treated
similarly to parties as you will see a bit later in these guidelines.

For example, in paternity cases bought on behalf of the child(ren) by the State of Washington, the state is a party and
each of the child(ren)’s parents are parties. The state in such cases is represented by the Deputy Prosecuting Attorney.

2. A guardian ad litem is appointed to represent the best interests of their client – usually a child (someone under age 18)
but sometimes an incapacitated adult. The client’s best interests and what the client wants are not always the same
things. An attorney would represent what a client wants. The role of the GAL and that of an attorney are not the same
although there are many things similar about what each may do.

Guardians ad litem, even those who are also attorneys licensed to practice law in the state of Washington, are not
allowed to give parties legal advice. However, except for dependency cases involving the Department of Children and
Family Services (also sometimes referred to as CPS), almost all of the GALs in this county (Grays Harbor County)
happen to be attorneys.

3. Except in dependency cases and contempt actions, parties are not generally entitled to have an attorney appointed by the
court to represent them in paternity cases, divorces (dissolution of marriage), or custody matters. If you want to hire an
attorney, you are free to do so in any case.

4. The GAL cannot guarantee the privacy of information obtained during the investigation unless the court has ordered
certain documents or other sensitive information is to be protected.

5. In most cases, the court has (or will) authorized the GAL to conduct random UAs or other drug testing of the parties.
When you are contacted by the GAL or a member of her staff with a request for a random drug test, you have four hours
in which to submit your sample to a licensed agency or your test will be considered “dirty”. In some cases, the court
may authorize the test(s) to be conducted at a specific place at either a reduced cost to you or at county expense. If you
are unable to go to that location to submit to your test, you are still responsible for locating an agency on your own and
submitting to the test within the set time limits. In those situations where you submit to a location other than one
authorized by the court as described above, it is also your responsibility to pay for the test. There are various types of
tests that the GAL may request. A brief description of each follows:

a) Standard UA. This is a standard urine test that screens for a multitude of substances. The cost for such tests at
private agencies varies from $25 to $50 or more. Your urine sample is sent to a certified laboratory and the sample is
tested for substances as well as for other indicators to reveal if your sample has been altered or adulterated in any way.
Test results indicating any type of tampering or that reveal a “positive” use of any substance that has not been
prescribed by your doctor are considered “dirty”. We do not accept “dip stick” aka “chem strip” or instacup tests or
computer generated tests. The only valid test results we will accept must be physically sent to a certified laboratory.

b) ETG UA aka Alcohol UA. This is a special urine test that specifically screens for the use of alcoholic
beverages. It is performed in addition to the testing for a Standard UA. The cost for such tests at private agencies varies
from $40 to $70 or more.

c) Hair Follicle Tests. This is a special test that measures use of several types of substances and provides a look-
back period of 90 to 365 days. The cost for this test is currently about $130.00 to $150.00 or more.

Page 1 of 2
GAL Guidelines
2023
 You MUST sign a release that authorizes the testing agency to send your test results directly to the GAL. The GAL will
only accept test results received from a certified agency as a result of a request for a random UA made by the GAL.
Any other test results brought in by you or a third party will not be considered valid.

6. The GAL and her staff are neither your friends nor your enemies. They are simply doing a job that they have been
trained to do and assigned to perform by the court. Every effort will be made to be courteous to you and to explain this
process to you but the same courteous conduct is also expected of you. However, threatening or other inappropriate
conduct by you or persons you bring to your appointments will not be tolerated. Such conduct and/or your refusal to
cooperate with the GAL will be documented and reported to the court and other appropriate authorities.

7. The GAL is an information gatherer and is not allowed to give information about your case to persons who are either
not parties or who are not lawyers or GALs or other relevant professionals involved in the case. For this reason, the
GAL will not generally accept telephone calls from or make calls to your family members or friends. If your family
members or friends have information you feel is important for the GAL to have, such persons are welcome to provide
such information to the GAL by writing her a letter.

8. If the court has ordered that your visits are to be supervised, the GAL may require you and the supervisor (if someone
other than a professional supervisor) to review and sign a set of rules for supervised visitations. Your failure to do so
may result in your request for visits being denied.

9. Except to deliver documents, please do not drop by the GAL’s office without first making an appointment. If you do
so, it is highly probable that the GAL will not interrupt other work to see you. You must realize that the GAL is
working on cases other than just yours and by interrupting that work, you could be jeopardizing the investigation for
someone else’s case or possibly even your own. Please be courteous and schedule appointments in advance. If you
have a question, please call. It is likely that the GAL or her staff can answer your question immediately. If they cannot,
please leave a detailed message with the staff or on our voice mail and someone will return your call with an answer as
soon as possible. Ordinarily you will have only one in-person appointment with the GAL except when exceptional
circumstances exist.

10. Although you will not normally be required to call the GAL’s office each week to check in, you are expected to
promptly notify the GAL’s office if your address or telephone number has changed. If you are requested to check in
with the GAL on some specific periodic basis (i.e. weekly, bi-weekly, etc.), please do so as your failure to do so will be
documented and reported to the court. When calling to “check in”, you do not necessarily need to speak directly to the
GAL. Rather, you can normally speak with a member of her staff who will know if there is specific information to be
given to you or that you are to provide for the GAL.

11. If you are required to have an evaluation of any kind (i.e. chemical dependency evaluation, psychological evaluation,
anger management evaluation, domestic violence evaluation, parenting evaluation, etc.), you must sign a release
authorizing the evaluator to share information with the GAL and to provide documentation to the GAL. The same is
true if you enter into treatment. Each treatment provider usually will have their own authorization and release form that
they prefer. If they do not, the GAL will provide you with one that is usually accepted by treatment providers.

12. As a general rule, you are not to discuss or make any mention or reference about the court proceedings, the other parent,
or any other person involved in your case with the children. It is generally also not a good idea to ask your attorney to
speak with your children either. If appropriate and if necessary, the GAL will meet with your children. The GAL can
also usually answer their questions in a more appropriate way.

13. If your case is a “county pay” case, do not send payments to the GAL. You will be billed by the county and your
payments should be made at the Court Clerk’s office in Montesano. If your case is a “private pay” case, you are
expected to pay a retainer from which the GAL will be paid. When the retainer has been nearly consumed, you will be
asked to replenish it and must do so before the GAL will continue the work that remains to be done. If you do not know
which type of case your case is, please feel free to ask the GAL or her staff.

We look forward to working with you to resolve the issues in a manner that meets the best interests of your child(ren).

Page 2 of 2
GAL Guidelines
2023
 GUARDIAN AD LITEM QUESTIONNAIRE

The information provided in this form will be used by the guardian ad litem in forming a
recommendation to the court as to the issues in this case as well as giving the guardian ad litem
information necessary to prepare a parenting plan. If you have written materials to supplement
your responses, please attach it to this packet. PLEASE ANSWER ALL QUESTIONS TO THE BEST
OF YOUR ABILITY. IF A QUESTION DOES NOT APPLY, ANSWER BY WRITING “N/A” IN THE
SPACE PROVIDED. If you need additional space for complete your responses, please attach
additional sheets.

PERSONAL INFORMATION

Your full name: __________________________________________________________

Have you been known by any other name? [ ] Yes [ ] No; If yes, please state the names you have used:
_____________________________ _____________________________________

Your Street Address: __________________________________________________________

Your Mailing Address: ____________________________________________________________
Your Email Address: _____________________________________________________________
Your Social Security Number: ____________________________________________________
Your Driver License Number: ______________________________ Washington DL? [ ] yes [ ] no
Your Phone Numbers: Home______________ Work _______________ Msg:_____________
Your Birth Date & Place of Birth:________ __________________________________________
Are you a US Citizen? [ ] yes [ ] no If not, do you have a visa or green card? [ ] yes [ ] no
If a visa or green card, what is its ID number? ________________________
Education completed: ______________________ Where? ____________________________
Have you or the other parent (if any) ever been married to anyone else? If so, date(s) of marriage(s),
date(s) of divorce(s), name of spouse(s):___________________________________________________
____________________________________________________________________________________

Have you or the other parent participated in counseling of any kind? If so, briefly describe when, where,
and the reasons/results. ________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Describe your general health and list any present or chronic illnesses. ___________________________
____________________________________________________________________________________
____________________________________________________________________________________

Have you or the other parent ever been charged with a crime (including traffic offenses) or arrested? If
so, describe when, where, the charges, & the outcome.________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

GAL Questionnaire - 1
Please provide your employment history over the last five years beginning with the most recent (or
current) employer:
Name of Employer Occupation Dates Employed Wages/Month

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________

If presently employed, what are your normal work hours? ______________________________

List your home addresses for the last five years:

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Do you or the other parent have any children other than those involved in this case? If so, state their
name(s) and ages, the name of the other parent, who the children live with, their address, when you last
saw them, who pays for their support, how much support is paid, is their a support order in
effect?_______________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Do you currently live with anyone? If so, name the person and describe your relationship with such
person(s).____________________________________________________________________________
____________________________________________________________________________________

INFORMATION REGARDING OTHER PARTY

The full name(s) by which the other parent goes or has been known: ____________________________
____________________________________________________________________________________
Address: _____________________________________________________________________________
Date of Birth: ________________________ Birthplace:________________________________________
Is this parent a US Citizen? [ ] yes [ ] no If not, does he/she have a visa or green card? [ ] yes [ ] no
Other parent’s Driver License Number: ________________________ Washington state DL? [ ] yes [ ] no
Education completed: _______________ Where? ____________________________________________

Describe his/her general health and list any known present or chronic illnesses:_____________________
____________________________________________________________________________________
____________________________________________________________________________________

Please provide his/her employment history over the last five years beginning with the most recent (or
current) employer:
Name of Employer Occupation Dates Employed Wages/Month

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

GAL Questionnaire - 2
If presently employed, what are his/her normal work hours? ____________________________________

List his/her home addresses for the last five years:

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________

Does he/she currently live with anyone? If so, name the person and describe the relationship with such
person(s).____________________________________________________________________________
____________________________________________________________________________________

PARENTAL HISTORY

When did you and the other parent separate? _______________________________________________

Briefly describe the marriage or relationship and the reasons for separation or divorce.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

PARENTING ISSUES

Who is the child(ren) living with? [ ] Mother [ ] Father [ ] Other (explain)________________________

____________________________________________________________________________________
____________________________________________________________________________________

How long has this child(ren) resided with this parent? Was it agreed or court
ordered?_____________________________________________________________________________
____________________________________________________________________________________

Describe the current visitation/parenting arrangements.

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Are these visitation/parenting arrangements voluntary or court ordered? __________________

IF YOU ARE THE CUSTODIAL PARENT, WHAT DO YOU WANT THE PARENTING/VISITATION
ARRANGEMENTS TO BE FOR THE OTHER PARENT? IF YOU ARE THE NON-CUSTODIAL PARENT
BUT ARE ASKING TO BE DESIGNATED AS THE PRIMARY CUSTODIAN, PLEASE INDICATE WHAT
YOU WOULD WANT THE OTHER PARENT’S VISITATION TO BE AND WHY YOU FEEL YOU ARE
THE MORE APPROPRIATE PERSON TO BE AWARDED PRIMARY CUSTODY: (check all appropriate
boxes)

[ ] Alternate weekend visits

[ ] to include overnight stays
[ ] no overnight stays – specify

[ ] Alternate holiday visits

[ ] Extended visits during winter, summer, and spring vacations

[ ] No restrictions need to be imposed

[ ] Restrictions need to be imposed – specify why

GAL Questionnaire - 3
[ ] Joint decision-making
[ ] Sole decision-making to custodial parent – specify why

Why do you feel you are the more appropriate primary custodian:_______________________
____________________________________________________________________________________

Are you claiming that the other party has parental inadequacies or problems that affect the child(ren)? If
so, describe the problems as you see them. ________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Are either you or the other party claiming that there are issues of drug abuse, alcohol abuse, physical or
sexual abuse of the children or spouse, mental illness or other serious problems? If so, please describe.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Describe your strongest or best qualities as a parent.__________________________________________

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Describe the other party’s strongest or best qualities as a parent. _______________________________

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

INFORMATION ABOUT THE CHILD(REN)

Name Date of Birth/Place of Birth Age

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Do any of the above listed children have special health problems? [ ] Yes [ ] No If yes, please describe.
____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Are the child(ren)’s vaccinations, medical, dental, and vision care needs and requirements up to date? If
not, why? ____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Name each child’s doctor, dentist, and optician. ______________________________________________

____________________________________________________________________________________
____________________________________________________________________________________

Do any of the children have any special behavioral or emotional problems? If so, describe the problem
and provide the name of the child’s counselor, if any. _________________________________________

GAL Questionnaire - 4
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Describe each child’s performance in school over the last 3 years (if applicable) including social skills and
academic grades.______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Name each child’s schools and teachers for the last three years._________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

What are your hopes and expectations for each child’s future? __________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Has CPS/DCYF been involved with respect to you or your children regardless of whether that has been
during the current case in court? ___________ If so, please provide the name and phone number of the
social worker assigned to your case: ______________________________________________________
____________________________________________________________________________________

Describe anything else which you want the guardian ad litem to know. (Attach additional pages if
necessary) _________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and
correct to the best of my knowledge and belief.

Signed at _____________________________ on _______________________________.

(City and State) (Date)

______________________________________
(Your Signature)

______________________________________
(Print your name)

GAL Questionnaire - 5
 REFERENCES

Please provide the following information for people you would like the guardian ad litem to contact about
you. Please list no more than two relatives. PLEASE BE ADVISED WE MAY NOT ACTUALLY
CONTACT THESE PERSONS (OR ANY OF THEM) BUT IN THE EVENT WE FIND IT APPROPRIATE
TO DO SO, WE WOULD LIKE TO HAVE THE INFORMATION.

Name:_______________________________________________________________________________
Address:_____________________________________________________________________________
Telephone: ___________________________ Relationship to you:_______________________________
What information do you expect this person to furnish? ________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Name:_______________________________________________________________________________
Address:_____________________________________________________________________________
Telephone: ___________________________ Relationship to you:_______________________________
What information do you expect this person to furnish? ________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Name:_______________________________________________________________________________
Address:_____________________________________________________________________________
Telephone: ___________________________ Relationship to you:_______________________________
What information do you expect this person to furnish? ________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Name:_______________________________________________________________________________
Address:_____________________________________________________________________________
Telephone: ___________________________ Relationship to you:_______________________________
What information do you expect this person to furnish? ________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

We welcome input from anyone who would like to send us information regarding this case and the
parties to this case, however, all such information should be provided to us in writing by mail.
Time and resources, among other reasons, simply do not allow us to accept calls from such
individuals.

GAL Questionnaire - 6