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SUPERIOR COURT OF CALIFORNIA
COUNTY OF FRESNO
(First) (Middle) (Last) (Nickname, Aliases, Maiden Name)
(Number and Street Name) (Apartment No.)
Address:
State:
Phone
Number(s):
OTHER PARENT / PARTY’S PERSONAL INFORMATION
Other Parent’s / Party’s Name:
Employer (If Unemployed, Please Write “Unemployed”):
Name: Phone Number:
Name DOB School Name DOB School
OTHER ADULTS IN YOUR HOME
Name DOB Relationship Name DOB Relationship
DOMESTIC VIOLENCE
1.
Is there currently a Restraining Order in effect protecting you or the other parent?
YES
NO
Expiration date:
2.
Are you, under penalty of perjury, alleging that there is a history of domestic violence between you and the other parent?
YES NO
3. If you answered YES to question #2:
YES NO
YES NO
4.
Were the child/ren present during the violence? NO Was medical attention required? YES
Were any weapons involved? NO Was Law Enforcement involved? YES
YES NO
If yes to #4, would you like for the FCS staff to provide you with information about creating a Safety Plan:
YES NO
If you answered ‘YES’ to questions #2 and #4, please immediately contact Family Court services by calling (559) 457-2100 and selecting
option #4 to receive a packet regarding your request for separate mediation sessions.
FAMILY COURT SERVICES TIER 1 INTAKE FORM
Case Number:
Are you requesting a separate mediation session due to a history of domestic violence between you and the other parent?
PFC-15 R06-20
MANDATORY
FAMILY COURT SERVICES TIER 1 INTAKE FORM
Email:
MINOR CHILDREN IN THIS CASE
