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SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO (California)

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PFC-46 E09-12
Domestic Violence Request for Separate Counseling Session
1 of 1
SUPERIOR COURT OF CALIFORNIA • COUNTY OF FRESNO
FAMILY COURT SERVICES
REQUEST FOR SEPARATE COUNSELING SESSIONS
PERSONAL INFORMATION
Name:
Date of Birth:
(First) (Middle) (Last)
Phone Number(s):
( )
( )
(Home) (Work) (Message / Cell)
OTHER PARENT / PARTY’S PERSONAL INFORMATION
Other Parent’s / Party’s Name:
Date of Birth:
(First) (Middle) (Last)
DOMESTIC VIOLENCE
Is there currently a Restraining Order in effect: YES NO (If ‘YES’, provide expiration date of the Order)
Has there ever been any police involvement and/or arrests related to domestic violence between you and the other parent:
YES NO (If ‘YES’, please provide the following information)
Date:
Location where the
incident occurred:
Reason for Arrest or Police Involvement:
Police
Report
Numbers
Name & Phone Number
of Parole / Probation
Officer
Please answer the following questions regarding the domestic violence between you and the other parent:
Were your children present during the violence:
YES NO
Were police called:
YES NO
Were any weapons involved:
YES NO
Were charges filed:
YES NO
Was medical attention required:
YES NO
Type of injuries:
Are there police/sheriff reports:
YES NO
If ‘YES’, list report numbers:
Estimate the total number of violent incidents:
Within the past year, has the frequency:
Increased Decreased Remained the same
I would like for the Family Court Services staff to provide me with information about creating a Safety Plan and/or information about
services for Victims of Domestic Violence: YES NO
I am aware that my separate session will be assigned based on Family Court Services availability and I will not be able to
reschedule the newly assigned appointment
I am aware that I may not be able to respond to the statements made by the other parent during their separate session with the
counselor
I am aware that I have the option to participate in a joint mediation session and bring a support person to provide me with
emotional support
I declare under penalty of perjury, under the laws of the State of California, that the foregoing information, as
provided in this entire form, is true and correct.
(Date)
(Signature)
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SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO (California)

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Completed 1 January 2021

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