IN THE DISTRICT COURT FOR THE 		 JUDICIAL DISTRICT
FOR THE STATE OF IDAHO, IN AND FOR THE COUNTY OF 				

In the Matter Of:

						,
(Petitioner’s Initials)

A Minor Child, Petitioner.
	
Case No. 					

MINOR'S PETITION FOR JUDICIAL AUTHORIZATION FOR A PHYSICIAN TO PERFORM AN ABORTION, 
I.C. §18-609A

Petitioner asks for a court order authorizing a physician to perform an abortion on Petitioner, and states:
1.	This Court has jurisdiction under Idaho Code §18-609A.
2.	My initials are:			.
3.	My age is:		_____.
4.	I am approximately 		 weeks pregnant.  
5.	 I have discussed getting an abortion with my parent(s) or guardian(s) and they have refused to consent to my having an abortion.   or 
 I have not discussed getting an abortion with my parent(s) or guardian(s) and do not want them to know of this request.   
6.	 I have been fully informed of the risks and consequences of the abortion by 														
7.	I am mature and capable of giving informed consent to the abortion for myself.

8.	If the court does not authorize the abortion based on my maturity and capacity to consent, the court should find that causing or performing the abortion, despite the absence of the consent of a parent, is in my best interest because 																																																				
9.	I understand that if I do not have an attorney who signs this Petition the court will appoint 	an attorney to assist me and represent my interests before the court at no cost to me.    
10.	I understand the court may also appoint a guardian ad litem to help ensure my best 	interests are considered.
11.	I understand a confidential hearing will be held within 48 hours, not including weekends, 	and holidays, after I file this petition.
12.	The court may contact me at/through:  
a.	(address) 																							
b.	(phone) 												
13.	(optional)    I want the court to consider the following additional information before the 	hearing: 
																																																													
Requested Relief
1.	 I ask the Court to schedule a hearing within 48 hours from the date this Petition is filed; and
2.	 I ask the Court to enter an order authorizing a physician to perform an abortion on me.

Date: 					

													
						 	 Petitioner (initials)

If an attorney has assisted in the preparation of this document:

Date: 					

													
Typed/printed name					 	Attorney’s Signature 
							Phone: 					
							Address: