Child Custody Recommending Counseling Questionnaire - Continued RI-FL024
VII. HISTORY OF DOMESTIC VIOLENCE
If you do not feel safe meeting with the other parent and the recommending counselor together, please
inform the clerk at the check-in window immediately.
Has there been a history of domestic violence between you and the other parent?
Is there a domestic violence or any other restraining order type currently in effect?
Have the police or other law enforcement ever been called due to domestic violence between you and
If yes, please explain (how many times, was anyone arrested, where this occurred, etc.):
Have you received medical care from a doctor or hospital because of injuries due to domestic
violence between you and the other parent?
Yes If yes, please explain:
Have any of your children been present when the domestic violence occurred?
If there is a history of domestic violence between you and the other parent, or you have a
restraining order against the other parent, you are entitled to have a separate child custody
recommending counseling session (separate from the other parent) and to have a support person with you
during the child custody recommending counseling appointment and at the court hearing. The child
custody recommending counselor will discuss with you the court rules and policies regarding the use of a
support person during the session.
I am willing to meet with the other parent together with the child custody recommending counselor.
I am requesting to meet separately with the child custody recommending counselor.
I declare under penalty of perjury that the information in this section regarding the history of domestic
violence is true and correct.
Adopted for Optional Use
Riverside Superior Court
RI-FL024 [Rev. 06/01/18]
CHILD CUSTODY RECOMMENDING COUNSELING