SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE
RI-FL024
Please note that the child custody recommending counseling process is
confidential to the extent that information about your case will only be shared with
those authorized to receive this information, which includes the court. The
recommending counselor is also required by law to report to the Department of
Public Social Services or law enforcement reasonable suspicion of child abuse or
neglect, or if any of the parties (including the children) present a danger to self or
others.
For Court Use Only
CONFIDENTIAL
DATE:
CASE NAME:
CASE NO:
CHILD CUSTODY RECOMMENDING COUNSELING INTAKE QUESTIONNAIRE
I. GENERAL INFORMATION
Your Name:
Age:
(FIRST) (MIDDLE) (LAST)
Current Address:
City:
State:
Zip Code:
How long have you lived at this address?
Phone:
(  )
Name of Employer:
Work Location:
Occupation:
Length of Employment:
Work Schedule
(Days/Times):
Day(s) off:
II. INFORMATION ABOUT THE CHILDREN INVOLVED IN THIS CASE
Name
Male/
Female
Date of
Birth
Age
Name of School and Hours of
Attendance
Grade
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Adopted for Optional Use
Riverside Superior Court
RI-FL024 [Rev. 06/01/18]
CHILD CUSTODY RECOMMENDING COUNSELING
QUESTIONNAIRE
riverside.courts.ca.gov/ocalfrms/localfrms.shtml
CHECK IN TIME: __________
Child Custody Recommending Counseling Questionnaire - Continued RI-FL024
1.
Is Child Protective Services (CPS) currently involved with your children?
No
Yes
If yes, please explain:
Social Worker Name:
County:
Telephone:
2.
Have there ever been any Child Protective Services (CPS) referrals made regarding any of your
children?
No
Yes
If yes, please explain:
3.
Do any of your children have special educational, medical or emotional needs?
No
Yes
If yes, please explain:
4.
Are any of your children in counseling?
No
Yes
Past
Current
If yes, please explain:
How long have they been in counseling?
How often do your children attend counseling?
Counselor’s Name:
Telephone:
5.
Are any of your children on medication?
No
Yes
If yes, please explain:
III. INFORMATION ABOUT OTHER CHILDREN LIVING IN YOUR HOME NOT INVOLVED IN YOUR CASE
Name
Male/Female
Age
Relationship to you
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Adopted for Optional Use
Riverside Superior Court
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CHILD CUSTODY RECOMMENDING COUNSELING
QUESTIONNAIRE
riverside.courts.ca.gov/ocalfrms/localfrms.shtml
Child Custody Recommending Counseling Questionnaire - Continued RI-FL024
IV. INFORMATION ABOUT OTHER ADULTS LIVING IN YOUR HOME
(Please list anyone other than your spouse/significant other)
Name
Date of Birth
Age
Relationship to you
V. INFORMATION ABOUT YOU AND THE OTHER PARENT
1.
What is your relationship with the other parent of the children involved in this case?
(Please check all that apply)
a.
We are currently married or registered domestic partners.
b.
We used to be married or registered domestic partners.
c.
We live together.
d.
We used to live together.
e.
We are dating or used to date.
f.
We were never in a committed relationship.
g
We were married. Date married:
h.
We are separated. Date separated:
i.
We are divorced. Date divorced:
2.
Are you in a current relationship with someone other than the other parent?
No
Yes
If yes, please answer the following: (Please check all that apply)
a.
We are currently married or registered domestic partners
b.
We are living together.
c.
We are dating but do not live together.
d.
We have children from this relationship.
Name of Spouse/Significant Other:
Date of Birth:
Age:
3.
Do you
or the other parent
have any special medical needs?
No
Yes
If yes, please explain:
4.
Are you
or the other parent
in counseling?
No
Yes
If yes, please provide the following information:
Counselor’s Name:
Telephone:
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Adopted for Optional Use
Riverside Superior Court
RI-FL024 [Rev. 06/01/18]
CHILD CUSTODY RECOMMENDING COUNSELING
QUESTIONNAIRE
riverside.courts.ca.gov/ocalfrms/localfrms.shtml
Child Custody Recommending Counseling Questionnaire - Continued RI-FL024
5.
Have you
or the other parent
been hospitalized for psychiatric reasons?
No
Yes
If yes, please explain:
6.
Are you
or the other parent
taking any medication?
No
Yes
If yes, please explain:
7.
Is there drug or alcohol use by you
or the other parent
?
No
Yes
If yes, please explain:
8.
Have you
or the other parent
ever been arrested or convicted of a crime?
No
Yes If yes, please explain (what charges were filed, what was the outcome of the charges,
where were the charges filed, etc.):
VI. CUSTODY AND VISITATION PARENTING PLAN
1.
Are there any existing custody and visitation orders regarding your children in Riverside County
or in any other county or State?
No
Yes (if yes, explain below):
Family Law Court County/State:
Case No.
Juvenile Court County/State:
Case No.
Other Court County/State:
Case No.
What are the orders?
2.
How are you currently sharing the children with the other parent?
Please explain the current time share schedule:
3.
How would you like to share your children with the other parent? (DO NOT USE Percentages %)
Please explain what schedule you think would be best for your children (be specific with days/times)
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Adopted for Optional Use
Riverside Superior Court
RI-FL024 [Rev. 06/01/18]
CHILD CUSTODY RECOMMENDING COUNSELING
QUESTIONNAIRE
riverside.courts.ca.gov/ocalfrms/localfrms.shtml
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.
1.
Has there been a history of domestic violence between you and the other parent?
No
Yes
If yes, please explain:
2.
Is there a domestic violence or any other restraining order type currently in effect?
No
Yes
County/State Ordered:
Case No.
Date ordered:
3.
Have the police or other law enforcement ever been called due to domestic violence between you and
the other parent?
No
Yes
If yes, please explain (how many times, was anyone arrested, where this occurred, etc.):
4.
Have you received medical care from a doctor or hospital because of injuries due to domestic
violence between you and the other parent?
No
Yes If yes, please explain:
5.
Have any of your children been present when the domestic violence occurred?
No
Yes
If yes, please explain:
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.
(SIGNATURE)
(DATE)
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Adopted for Optional Use
Riverside Superior Court
RI-FL024 [Rev. 06/01/18]
CHILD CUSTODY RECOMMENDING COUNSELING
QUESTIONNAIRE
riverside.courts.ca.gov/ocalfrms/localfrms.shtml
Child Custody Recommending Counseling Questionnaire - Continued RI-FL024
Case No:
VIII. Child Custody Recommending Counseling reports are typically available to you two (2) days
prior to your court hearing date. Please select how you would like to receive your Child Custody
Recommending Counseling report:
1.
I will pick up the report in person (photo ID required at the time of pick up)
2.
I would like my report sent electronically:
AUTHORIZATION FOR ELECTRONIC DELIVERY OF CCRC REPORTS
I am the
Petitioner
Respondent
Other:
on the above referenced case and hereby give authorization to the Riverside Superior Court to
send my Child Custody Recommending Counseling (CCRC) reports to the person(s) indicated
below electronically using the following method(s):
a.
E-Mail
i.
Name of Recipient:
Email Address:
ii.
Name of Recipient:
Email Address:
b.
Facsimile
i.
Name of Recipient:
Fax Number:
ii.
Name of Recipient:
Fax Number:
I give the Riverside Superior Court authorization to send my Child Custody Recommending Counseling
(CCRC) reports electronically.
(DATE)
(SIGNATURE)
Page 6 of 6
Adopted for Optional Use
Riverside Superior Court
RI-FL024 [Rev. 06/01/18]
CHILD CUSTODY RECOMMENDING COUNSELING
QUESTIONNAIRE
riverside.courts.ca.gov/ocalfrms/localfrms.shtml
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