Fill - Free fillable Travis County - Application for Intervention Services PDF form

TRAVIS COUNTY JUVENILE COURT

DOMESTIC RELATIONS OFFICE

1010 LAVACA P.O. BOX 1495 AUSTIN, TEXAS 78767 PHONE: (512) 854-9924 FAX: (512) 854-9819

ESTELA P. MEDINA

Chief Juvenile Probation Officer

SCOT M. DOYAL

Director

FRIEND OF THE COURT

INTERVENTION SERVICES APPLICATION

1010 Lavaca Street, P.O. Box 1495

Austin, TX 78767

512-854-9924 fax 512-854-9819

Any Non-Custodial and/or Custodial Parent may apply for services as long as the following criteria

are met:

1) Must have a final Court Order (this includes Divorce Decrees, Modification Orders, Paternity

Decrees or Orders Establishing the Parent-Child Relationship, and Protective Orders)

2) Must be willing to abide by all program rules and recommendations of staff

3) Must be willing to participate in a Conflict Resolution Meeting

4) Must complete all 6 Cooperative Parenting Forums

5) At least one of the parties must reside in Travis or contiguous counties

To apply for Intervention Services with the Access and Visitation Program, please complete an

application (currently available at the DRO offices and on the DRO website:

http://www.co.travis.tx.us/dro/visit.asp). Return the application along with a copy of each pertinent

court order. (Once you submit an application you will be scheduled for an appointment.)You will be

notified in writing of DRO’s acceptance and/or rejection of your case within 5 working days.

I certify that I have read, understood and agree to abide by the terms of the criteria for acceptance

in the Intervention Services by the Domestic Relations Office Access and Visitation Program

___________________________________

APPLICANT SIGNATURE

2

IMPORTANT INFORMATION

PLEASE READ BEFORE YOU PROCEED

Intervention Service cases do not qualify

for legal intervention through our office.

If at any time you feel the only recourse is

litigation you will need to Consult and/or

hire an attorney to file the appropriate

legal documents with the court.

In order for us to process your application, we ask that you

complete the entire application and acquire and keep in your

possession all required documents. Without the required

information, we will be unable to process your application.

A copy of the most recent court order must be attached to this

application. If you do not have one, you may obtain one from the

District Clerks Office in the County your order was issued

3

FRIEND OF THE COURT

ACCESS AND VISITATION-INTERVENTION SERVICES

CASE HISTORY

Name: ____________________________CAUSE#:_____________________DATE:___________________________

1. Why did you contact us? ________________________________________________________________________

____________________________________________________________________________________________

2. Are you a Custodial Parent? □ YES □NO

3. Do you have a final Travis County Court Order? □ YES □NO If no what County/State ____________________

4. Do you have an attorney or agency helping you with your visitation case? □ YES □NO

If yes, list the name, address and phone number of the attorney or agency

____________________________________________________________________________________________

5. What is the visitation schedule outlined in your order?

 1

st,

,3

rd

and 5

th

weekend starting at 6:00 pm on Friday through 6:00 pm Sunday

 2

nd

and 4

th

weekend starting at 6:00 pm Friday through 6:00 pm Sunday

 Other

 I don’t know

6. Have you made any “out-of-court” agreements with the other parent in regard to visitation with your children?

□ YES □ NO If yes, please explain _______________________________________________________________

____________________________________________________________________________________________

7. Has the other parent given you any reason or excuse why the visitation schedule outlined in your order is not

being followed? □ YES □ NO If yes, please explain ________________________________________________

_____________________________________________________________________________________________

8. How long ago was the last visit with your child(ren)

 1 week or less

 1 month or less

 6 months or less

 1 year or less

 More than 1 year

 Never had any visits

9. Have the police been called during exchanges? □ YES □ NO If yes, please explain ________________________

____________________________________________________________________________________________

4

10. Has the other parent ever alleged he/she is afraid of you? □ YES □ NO If yes, please explain ________________

____________________________________________________________________________________________

11. Has there ever been a physical altercation between you and the other parent. □ YES □ NO

If yes, please explain __________________________________________________________________________

_____________________________________________________________________________________________

12. Is there now or has there ever been a restraining order, protective order, or trespass warrant in effect against you,

the other parent or anyone else in either household? □ YES □ NO If yes, please explain ____________________

____________________________________________________________________________________________

13. Has Child Protective Services ever contacted you or the other parent? □ YES □ NO If yes, please explain

____________________________________________________________________________________________

14. Have you ever been accused, charged or convicted of sexual assault, indecency, injury or endangerment of a

child? □ YES □ NO If yes, please explain ________________________________________________________

____________________________________________________________________________________________

15. How long have you lived at your current address?

 Less than 6 months

 6 months – 1 year

 More than 1 year

16. Are you currently in a relationship? □ YES □ NO If yes, how does the other party get along with your current

Partner?

 Ok

 Does not like my current partner

 Likes my partner

 Does not want my partner to be around our child(ren)

 Does not know my partner

17. How does your child get along with your current partner?

 Ok

 Does not like my current partner

 Likes my partner

 Does not want to be around my partner

 Does not know my partner

5

18. Has there ever been a physical altercation between you and your current partner? □ YES □ NO If yes, please

Explain ____________________________________________________________________________________

____________________________________________________________________________________________

19. Do you have other children? □ YES □ NO If so, how does your child get along with these children?

 Ok

 Does not like my child(ren)

 Likes my child(ren)

 Does not want my child(ren) to be in our home

 Does not know my child(ren)

20. Does (Do) your child(ren) have any special medical needs? □ YES □ I DON’T KNOW □ NO

If yes, please explain __________________________________________________________________________

____________________________________________________________________________________________

21. How do you communicate with the other parent about your children?

 We don’t communicate

 By phone, mail or e-mail

 In person

 Through our child(ren)

 Through family members

22. If I was to ask the other parent if you ever had any issues with drugs and/or alcohol what would they tell me?

______________________________________________________________________________________________________

6

INFORMATION ABOUT YOU – (PLEASE PRINT)

I am the : □ CUSTODIAL PARENT □ NON-CUSTODIAL PARENT □ LEGAL GUARDIAN

Full legal name: ________________________________________________________________________________________________________

Last First Middle

Home address: _______________________________________________________________________________________________________

Street Apt. # City Zip

Telephone number: ( ) ____ ( ) ________ ( ) _________________________

Home Cell Work

Please provide the following information about yourself:

Date of Birth Social Security Number Drive License or ID Number

(include state)

Sex

M F

Email address__________________________________ other contact information__________________________________________________

Have you ever been arrested? □ YES □ NO If yes, for what offense: ____________________________________________________________

_____________________________________________________________________________________________________________________

Have you ever been in jail or prison? □ YES □ NO If yes, Date _______________________ Release Date_________________________

Have you ever been on probation, parole or received deferred adjudication? □ YES □ NO If yes, please provide:

Offense

Term of Probation/Parole

Date completed:

Parole/Probation Officer Name

Address

Phone #

( )

Have you used or are you currently using illegal drugs? □ YES □ NO If yes, please explain:

_____________________________________________________________________________________________________________________ |

_____________________________________________________________________________________________________________________

Do you have any outstanding warrants for your arrest? □ YES □ NO If yes,

What County/State? ________________________________ for what offense? ___________________________________________________

_____________________________________________________________________________________________________________________

XXX-XX-

7

INFORMATION ABOUT THE OTHER PARENT:

Full legal name: ______________________________________________________________________________________________________

Last First Middle

Current home address: ________________________________________________________________________________________________

Street Apt. # City Zip OR

Last known home address: _____________________________________________________________________________________________

Street Apt. # City Zip

Telephone number: (______)____________________(_______)_______________________(_______)________________________________

Home Cell Work

Email address________________________________________ other contact information__________________________________________

Does He/She have an account on a social network site (i.e. facebook, MySpace etc.) □ YES □ NO If yes please provide detailed information

_____________________________________________________________________________________________________________________

Marital status: Is the other parent currently married? □ YES □ NO

Please name all individuals who live with the other parent and identify their relationship_____________________________

_________________________________________________________________________________________________________

Has the other party ever been arrested? □ YES □ NO If yes, for what offense: _________________________________________________

Has the other party been in jail or prison? □ YES □ NO If yes, Date ______________________Release Date__________________________

Has the other party been on probation, parole or received deferred adjudication? □ YES □ NO If yes, please provide:

Offense

Term of Probation/Parole

Date completed:

Parole/Probation Officer Name

Address

Phone #

( )

Has the other party used or is currently using illegal drugs? □ YES □ NO If yes, please explain: ___________________________________

Does the other party have any outstanding warrants for their arrest?

□ YES □ NO If yes, What County/State? _____________________________For what offense? __________________________

8

DEMOGRAPHIC INFORMATION

How did you find out about this office?

□ Self □ Court □ Child Support Office □ Domestic Violence Agency □ Child Protection Agency □ Law Enforcement Other

What is your relationship to these children?

□ Father   Mother □ Grandparent   Legal Guardian   Other

How many children are involved in this case? _______________

At the time that the children involved in this case were born you were:

□ Not Married to the other Parent

□ Married to the other Parent |

□ Separated from the other Parent |

□ Divorced from the other Parent |

Are you currently married? YES □ NO

If yes, do you have children from this marriage? YES NO

If yes, how many children do you have from your current marriage (do not include step-children) __________

How many other children are you responsible for? (does not include stepchildren or children with your new partner) _________________

ETHNICITY INCOME (IN THOUSANDS)

□ AMERICAN INDIAN /ALASKA NATIVE □ LESS THAN $10,000

□ ASIAN AMERICAN / PACIFIC ISLANDERS □ $10,000 – 19,000

□ BLACK/AFRICAN AMERICAN □ $20,000 – 29,000

□ WHITE □ $30,000 – 39,000

□ HISPANIC □ $40,000 AND ABOVE

□ MULTI-ETHNIC

INFORMATION ABOUT THE CHILD(REN)

Name: ________________________________________________ Name: ____________________________________________________

Address: _______________________________________________ Address: ___________________________________________________

Date of Birth: _________________ Sex: ______________________ Date of Birth: ______________________Sex: _____________________

Name: ________________________________________________ Name: ____________________________________________________

Address: _______________________________________________ Address: ___________________________________________________

Date of Birth: _________________ Sex: ______________________ Date of Birth: ______________________Sex: _____________________

Name: ________________________________________________ Name: ____________________________________________________

Address: _______________________________________________ Address: ___________________________________________________

Date of Birth: _________________ Sex: ______________________ Date of Birth: ______________________Sex: _____________________

9

COURT-ORDERED POSSESSION INFORMATION

Name of final order in which current possession was established - DO NOT INCLUDE TEMPORARY ORDERS

_____________________________________________________________________________________________________________________

Date order was signed: ___________________________ Is the order a Travis County order? □ YES □ NO

If no what County/State _______________________________________|

For Custodial Parent only:

Have you been or are you now on probation in Travis or another County for failure to allow possession? □ YES □ NO

If yes, please provide detailed information____________________________________________________________________________________|

______________________________________________________________________________________________________________________

For Non-Custodial Parent only:

Is the person with primary possession currently/or previously been placed on probation in Travis or another County for failure to allow |

|possession? □ YES □ NO If yes, please provide detailed information____________________________________________________________||

_____________________________________________________________________________________________________________________

IF OTHER THAN EL PASO COUNTY WHERE? IF

Has Child Protective Services (CPS) or any law enforcement authority contacted you with regard to the child(ren)? □ YES NO

If yes, please provide detailed information___________________________________________________________________________________|

________________________________________________________________________________________

I declare all the above information provided is true and correct. I am aware that should there be any

falsification or failure to fully disclose information requested, my application may be rejected, or the

Domestic Relations Office may close my case without further explanation. I understand that it is at the

sole discretion of the Domestic Relations Office to accept or reject any application.

______________________________________________ ______________________________________

APPLICANT SIGNATURE DATE SIGNED

For office use only

Services provided by

DRO:

□ Mediation

□ Counseling / Access Facilitation

□ Parenting Plan

□ Education / Cooperative Parenting Classes

□ Guidelines/Ct order

□ Monitored visit

□ Supervised visit

□ Neutral drop-off

Parenting time increased?

□ Yes □ No

Case Opened_________________________

Date

Case Closed___________________

Date

Fill Online, Printable, Fillable, Blank Travis County - Application for Intervention Services Form

Related forms

Fillable Travis County - Application for Intervention Services

Fill Online, Printable, Fillable, Blank Travis County - Application for Intervention Services Form

Related forms

First 20 documents completely FREE!