Ventura — Family Court Services Intake Questionnaire

Source: https://ventura.courts.ca.gov/system/files/vn163.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF VENTURA FAMILY COURT SERVICES INTAKE FORM FOR CHILD CUSTODY RECOMMENDING COUNSELING (Confidential – For Court Use Only)

This form must be completed by all parties prior to the start of the Child Custody Recommending Counseling (CCRC) session. All files and records in Family Court Services are confidential, unless a mandated report is necessary (e.g. suspected child abuse or threats to harm yourself or others).

Your Name: ________________________________ Case Number: __________________________________ Do you have an attorney? ☐ Yes ☐ No Attorney Name: _______________________________________________ Do you need an interpreter for your CCRC/mediation session? ☐ Yes ☐ No Language: _____________________

DOMESTIC VIOLENCE & SAFETY CONCERNS

1. Have you ever experienced or witnessed any physical, emotional, or verbal abuse, ☐ Yes ☐ No threats, or controlling behavior from the other parent?
2. Has the other parent or any other individual involved in this case ever: a) Threated to harm or kill you, your children or themselves? ☐ Yes ☐ No b) Used or threatened to use a weapon against you? ☐ Yes ☐ No c) Tried to choke/strangle you? ☐ Yes ☐ No d) Become more aggressive or violent recently? ☐ Yes ☐ No e) Followed, harassed, or stalked you in person or online? ☐ Yes ☐ No f) Prevented you from leaving, calling for help, or seeking medical care? ☐ Yes ☐ No g) Threatened or tried to commit suicide? ☐ Yes ☐ No h) Used alcohol or drugs in a way that makes them more violent or unpredictable? ☐ Yes ☐ No
3. Have your children witnessed or been affected by domestic violence or any of the ☐ Yes ☐ No behaviors listed above?
4. Has a member of your household ever been involved in domestic violence? ☐ Yes ☐ No
5. Restraining Orders: a) Are there currently, or has there ever been, any restraining orders (Domestic Violence Restraining Order, Civil Harassment Restraining Order, Elder Abuse/Dependent Adult ☐ Yes ☐ No Restraining Order, Criminal Protective Order, Emergency Protective Order, etc.) involving you, the other parent, or the children? b) Has the other parent or anyone involved in this case violated a restraining order or ☐ Yes ☐ No any court-ordered restrictions?
6. Have you or the other parent been arrested or convicted of any crimes related to ☐ Yes ☐ No domestic violence, substance abuse, or child abuse?

Family Code Section 3181(b) states "If a party alleging domestic violence in a written declaration under penalty of perjury or a party protected by a protective order so requests, the mediator will meet with the parties separately and at separate times."

7. Are you requesting separate CCRC/mediation sessions? ☐ Yes ☐ No

Mandatory Form Page 1 of 2 VN163 (Rev. 07/25)

Family Code Section 6303(c) states: "If a court has issued a protective order, a support person shall be permitted to accompany a party protected by the order during any mediation orientation or mediation session, including separate mediation sessions." The mediator may exclude the support person from a mediation session if the person participates in the mediation, acts as an advocate, or the presence of the support person is disruptive to the process. The support person is bound by the confidentiality of the mediation.

8. Do you intend to bring a support person ☐ Yes ☐ No with you to mediation? Name of support person: ____________________________________

FIREARMS & WEAPON-RELATED SAFETY CONCERNS 9. Does the other parent or anyone involved in this case own, possess, or have ☐ Yes ☐ No access to any firearms, ammunition or other weapons? ☐ Unsure 10. Has the other parent or anyone involved in this case ever threatened to use or actually used a firearm or any other weapon to intimidate, harm, or scare you ☐ Yes ☐ No or the children or anyone else? 11. Do you believe the other parent’s access to firearms poses a current risk to ☐ Yes ☐ No you, your children, or others?

CHILD WELFARE & OTHER SAFETY ISSUES 12. Have you, the other parent, a member of your household, or the child ever had a ☐ Yes ☐ No referral, open case, or active case/investigation with the Department of Children and If yes, when? __________ Family Services (DCFS) or Child Protective Services (CPS) or Adult Protective Services? 13. Guardianship Cases: Is there a pending Guardianship case involving your child(ren)? ☐ Yes ☐ No 14. Juvenile Court Cases (Dependency): Is there an open or past Juvenile Court ☐ Yes ☐ No (Dependency) case involving your child(ren)?

CUSTODY & VISITATION HISTORY 15. Mediation Orientation: Have you completed the online ☐ Yes ☐ No If yes, date completed: ____________ orientation program? 16. Previous Mediation: Have you previously participated in ☐ Yes ☐ No CCRC/mediation with the other parent in this case? 17. Relocation Information: Have you or the other parent recently moved or planning to move out of Ventura ☐ Yes ☐ No County or California? 18. Child Custody Evaluation: Have you previously ☐ Yes ☐ No If yes, when? ________________ participated in a child custody evaluation?

By signing below, I acknowledge that the information provided is true and correct to the best of my knowledge.

Signature: ____________________________ Date: _______________________

Mandatory Form Page 2 of 2 VN163 (Rev. 07/25)