San Mateo — Information Sheet Mediation & Evaluation

Source: https://sanmateo.courts.ca.gov/system/files/local-forms/fcs-4-information-sheet-mediation-evaluation.pdf

Superior Court of California, County of San Mateo Family Court Services 400 County Center, 6 th Floor, Redwood City, CA 94063 Tel: (650) 261-5080 ~ Fax: (650) 261-5142

INFORMATION SHEET

Please fill out this form completely and bring it with you to your appointment. The information you provide will be used to assist in your upcoming appointment. Failure to bring the completed form with you will delay your appointment time. Please do not attach any additional pages.

YOUR CASE #: ________________

Personal Information

Name: ___________________________________________________________________________ Other names you have used: _________________________________________________________ Birthdate: _________________ Birthplace: ___________________________ Age: ______________ Do you have a valid driver’s license? ________ Home address: ____________________________________________________________________ City: ________________________________________ State: __________ Zip code: ____________ Mailing address: ___________________________________________________________________ City: ________________________________________ State: __________ Zip code: ____________ Home phone: _________________ Cell: _________________ Work / message: ________________ Email Address: _______________________________

Attorney Information (please complete if you have an attorney)

Name: ___________________________________________________________________________ Address: _________________________________________________________________________ City: ________________________________________ State: __________ Zip code: ____________ Telephone #: ________________________________ Fax #: _______________________________

Children Involved in This Matter

Name: _____________________ DOB: ____________ Age: _______ Lives with: _______________ Name: _____________________ DOB: ____________ Age: _______ Lives with: _______________ Name: _____________________ DOB: ____________ Age: _______ Lives with: _______________ Name: _____________________ DOB: ____________ Age: _______ Lives with: _______________

If your children have any special needs, please list them here:

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Your Residence

How long have you resided at your current address? ____________ Number of bedrooms: ___________ Do you rent or own? _____________ AreAre youyou planningplanning toto move?move? ________________ Where? _______________________ Names and relationship to you (including children) of all persons who live at this residence:

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Employment Information

Employer: ________________________________ Employer’s Address: _______________________________________________________________ Date employed: ____________________________ Days & hours of work: _____________________________________________________________ Job title: __________________________________

Status of Your Relationship With the Other Parent

Married / Domestic Partnership: ( ) Yes ( ) No Date of marriage / domestic partnership: _________ Date began living together: ____________________ Date of last separation: ___________________ Date divorce was final / domestic partnership was terminated: _______________________________

Other Marriages / Domestic Partnerships/ Other Children

Name: __________________________ Date: _______________________ Children from this relationship: _______________________________________________________

Name: __________________________ Date: _______________________ Children from this relationship: _______________________________________________________

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If the following is applicable, please read carefully and fill out completely. If it is not applicable, please skip and continue on the next page.

Domestic Violence / Restraining Orders

When there is a history of domestic violence or a domestic violence restraining order, the protected party may request a separate session and bring a *support person under Family Codes 3181 & 6303.

_____ I request a separate session under code section 3181 _____ I wish to bring a support person under code section 6303

Briefly describe any history of domestic violence:

Latest incident: __________________________________________________________________

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Other incidents:

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Were the police called / any police reports made? _______________ o If yes, in what city or county were they involved? ______________________________ o Police report #s (if you have them):_________________________________________ Was emergency medical treatment needed?

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Were weapons involved? __________________________________________________________ Was the Court involved? _______________ o If yes, in which county? ___________________________________________________ Were temporary restraining orders issued? ____________________________________________ Has anyone received counseling or help from a domestic violence agency? __________________ o If yes, where? __________________________________________________________ Have the children witnessed any of the domestic violence? ________ o If yes, briefly explain:____________________________________________________ _____________________________________________________________________

If you have a copy of a restraining order from another county or a criminal protective order, please provide a copy of the order to your recommending counselor.

*Support Person: The support person is there to provide moral and emotional support only. He/she cannot participate in the session or act as an advocate. The support person should not have a dual role (i.e. supervising the visits) or be a person whose presence would be disruptive to the mediation process (i.e. a significant other or a person who has conflict with the other parent). The mediator/ CCRC has the right to exclude a support person if there is a conflict of interest, if the support person’s presence is disruptive to the session, attempts to participate in the session, or the support person attempts to influence the session in any way. The support person must sign and adhere to the support person guidelines in order to support the survivor in the session.

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Current Parenting Plan/Schedule

Are the children seeing the other parent? _______ o If yes, what is the current parenting plan or schedule in which the child(ren) are with each parent?_____________________________________________________________________ ___________________________________________________________________________ o If no, what are the current circumstances preventing contact between the other parent and the children? ___________________________________________________________________ ___________________________________________________________________________

Do you or the other parent have any history or current issues with drug or alcohol abuse? _______ o If yes, please explain briefly:_______________________________________________ Are there any current charges of child physical or sexual abuse or neglect? ________ o If yes, please explain briefly:_______________________________________________ Has a dependency petition (W&I 300) been filed with the Juvenile Court? _______ o If yes, please explain briefly:_______________________________________________ Are there any concerns relating to the safety of the children? ________ o If yes, please explain briefly:_______________________________________________ Has Child Protective Services (CPS) ever been involved with your family? ________ o If yes, in which county? __________________________________________ o Please briefly explain their involvement and the outcome: ______________________________________________________________________

What custody / visitation challenges, if any, currently exist?

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Please list some reasonable solutions to the challenges: ___________________________________

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Under penalty of perjury, I certify all the information provided to Family Court Services is true and correct. I understand falsification or omission of any information may affect the disposition of my case. I understand that Family Court Services staff may consider all other information available regarding my Family Court Services case.

Signature: _______________________________________________ Date: __________________

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