Fillable FAMILY COURT SERVICES INTAKE QUESTIONNAIRE 1. Previous Mediation (California)

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FAMILY COURT SERVICES INTAKE QUESTIONNAIRE 1. Previous Mediation (California)

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  • 16 check-boxes
  • 7 other fields

Country of origin: US
File type: PDF

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FAMILY COURT SERVICES INTAKE QUESTIONNAIRE
1. Previous Mediation YES NO
Have the pa
rents previously participated in child custody mediation?
2. Interpreters Required
Is either pa
rent non-English speaking or limited in speaking English?
3. Parent Change of Residence
Has either parent recently m
oved or is planning to move out of the United States,
State of California, or County of Ventura?
4. Domestic Violence Concerns*
(a) Is there a Restr
aining or Protective order against either parent?
(b) Have there been any allegations of violence, abuse, or stalking committed
by
either parent against the other or the child?
5. Children or Adult Protective Services Involvement
Has either parent been contacted by
a Children’s or Adult Services Agency
concerning an abuse/neglect investigation?
6. Child Custody Evalua
tion
Have the parents participated or been ordered to participate in a child custody evaluation?
When?: _
_____________________________
7.
Party in J
ail or Prison
Identify any parent who is expected to be in jail or prison at the time of the Mediation:
___________________________________ ______________________________
Name of parent incarcerated Facility
8. Dependency Petitions
Have any dependency petitions been filed in Juvenile Court related to the parties
children?
____
_________________________________________ ______________________
Signature of Petitioner or Attorney for Petitioner Date
_____________________________________________ ______________________
Signature of Respondent or Attorney for Respondent Date
*Fam
ily Code Section 3181(b) states; “If any part
y alleging domestic violence in a written declaration under penalty of perjury
or a party protected by a protective order so requests, the mediator will meet with the parties separately and at separate times.”
THIS FORM TO REMAIN CONFIDENTIAL (Family Code §3177)
Mandatory Form
VN163 -
Rev.7/09
FAMILY COURT SERVICES INTAKE QUESTIONNAIRE
IN THE MATTER OF: ________________________________________
CASE NUMBER: _____
_______________________________________
FOR COURT USE ONLY
VN163
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FAMILY COURT SERVICES INTAKE QUESTIONNAIRE 1. Previous Mediation (California)

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Completed 1 September 2021

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