FM-1015A REV 07/24/2020 Page 2 of 2
For Mandatory Use
Domestic Partnership Date:
Date of Final Dissolution:
Is there a current custody/visitation order in effect? Yes No
If yes, please attach a copy of the custody/visitation order or bring a copy to your mediation session.
Have you been the victim of domestic violence? Yes No
Who committed the domestic violence? The other parent/party
Other (list name and relationship):
Briefly describe the kind of violence and how often it occurred:
When did the most recent violence occur?
RIGHT TO SEPARATE SESSIONS: If a party alleging domestic violence in a written declaration under penalty of
perjury, or a party protected by a protective order so requests, Family Court Services staff must meet with the
parties separately at separate times. (If you have a restraining order of any kind, please attach a copy or bring it
with you to your session.) If domestic violence is an issue in a case and both parents wish to be seen together,
Family Court Services must still begin all proceedings by interviewing each party separately.
Have you attached or are you planning to submit to Family Court Services a copy of the PROTECTIVE ORDER or a
WRITTEN DECLARATION UNDER PENALTY OF PERJURY alleging domestic violence? Yes No
If you answered “yes,” do you wish to be seen separately? Yes No
RIGHT TO A SUPPORT PERSON: If the court has issued a PROTECTIVE ORDER, a support person shall be
permitted to accompany protected party during any mediation orientation or mediation session, including separate
mediation sessions. It is the function of a support person to provide moral and emotional support. The support
person is not present as a legal adviser and shall not give legal advice.
Do you have a current PROTECTIVE ORDER? Yes No
Do you wish to have a support person accompany you in mediation? Yes No
Have you had a protective order in the past against the other party? Yes No
*** If you stated that you have been a victim of domestic violence, please obtain and complete a separate domestic
violence questionnaire from Family Court Services.
OTHER SAFETY RELATED ISSUES
Please briefly describe any other safety-related issues affecting any party or child named in the proceedings:
FEE REQUIREMENTS FOR SCREENINGS
Fee for above services are $160.00 per hour.
NO SHOW AND LATE CANCELLATION FEES:
A “NO SHOW” fee of $100.00 will be charged if either or both parties fail to appear (this includes arriving
over thirty minutes late).
A “LATE CANCELLATION” fee of $100.00 will be charged if notice of cancellation is less than 48 hours
(Mon. – Fri.) for mediation appointments.
Fee rates may be increased in the future at the direction of the Court.
Make checks or money orders payable to OFFICE OF THE COURT CLERK.
Application for Waiver of Court Fees and Costs are available if you are unable to pay the required fees. Your sworn
statement to this effect along with Income and Expense Declarations and required attachments detailing your
finances must be submitted to Family Court Services. Unreasonable or frivolous requests for modification of Court
fees may result in Court assessed penalties.
I understand that any audio, visual or other electronic recording of any communication with Family Court
Services staff is prohibited.
I declare that the information on this form, including any attachment, is true and correct and that this declaration is
executed on (date):
Signature
