[Court Heading and Caption. Should include the court name, plaintiffs and defendants and case number.]

Petition for Temporary Restraining Order to Prevent Removal
of Child to Foster Home Outside Vicinity of Parent 
 
    

COMES NOW [name of parent] and, pursuant to [cite statute], requests that this court enter a temporary restraining order directing the [government agency] not to transport the minor child, [name], outside of the County of _________, State of _________, so that [child] might continue to be available for visitation with [parent]. 
    

As grounds for this request [parent] states as follows: 
    

1. Since the written decision of the [specify juvenile court] was issued on [date], stating that the legal and physical custody of [minor child] was to remain with the [government agency], [parent] has had at least _________ visits with the minor child, [name], on the premises of [institution] at [location]. 
    

2. The [government agency] has informed [parent] and [her or his] counsel of record that [government agency] intends to transport [child] to a foster home in the City of _________, County of _________, State of _________, and that they intend to accomplish this transfer of [minor] within a few days. 
    

3. [Parent] will suffer immediate and irreparable injury by reason of the child's being transported to another location to live, because [she or he] will then no longer be able to have weekly visits with [her or his] minor child. 
    

4. [Parent] is currently dependent on [state source of income, such as: Social Security income] to supply all of [her or his] material needs, and will be unable to afford to travel to such new location to visit [her or his] child more than _________ times a year. 
    

5. [Parent] feels that this will, in effect, terminate any [state relationship, such as: mother-daughter] relationship which at present exists between petitioner and [her or his] child, and will therefore deprive [parent] of the basic parental right to maintain contact and relationship with [her or his] child. 
    

6. The injury to [parent] which will result from the threatened acts of the [government agency] is such that on a balancing of the equities between the [government agency] and the [parent], this court should grant this application pending a hearing on the request for a preliminary injunction. 
    

WHEREFORE, [parent] requests that this court enter a temporary restraining order directing the [government agency] to refrain from transporting the child, [name], outside of the County of _________, State of _________, and to make the child available on some reasonable basis to [parent] for visitation pending a hearing on petitioner's request for a preliminary injunction or pending further court order. 
    

[Signature, Verification, Etc.]