Kern — KRN SUP CRT PB-8524

Source: https://www.kern.courts.ca.gov/system/files/general/guardianship_questionnaire.pdf

Family Court ServicesSUPERIOR COURT OF CALIFORNIA 1215 Truxtun Avenue, 3rd Floor COUNTY OF KERN Bakersfield, California 93301 Patricia Arredondo, LCSW Telephone: (661) 610-6700 Manager of Family Court Services Fax: (661) 688-7214 Mediation & Investigation Email: FCS@kern.courts.ca.gov

Guardianship Questionnaire

Instructions:

MAKE SURE TO READ AND FOLLOW ALL THE INSTRUCTIONS IN ORDER TO AVOID ANY DELAYS IN YOUR CASE.

You are receiving this questionnaire because you are a party to a relative guardianship case. This questionnaire is a vital piece of the guardianship petition. The court has the authority to order an investigation as part of the case proceedings. Therefore, it is important the entire packet is completed and returned along with your petition to the Probate Court window.

This questionnaire is confidential and will not become part of the public record. The personal identifying information will be kept in a confidential location at all times.

All persons who are 18 or older who live in the home are required to undergo a background check. Therefore, they are required to complete the “Background Information” page of this packet. Make additional copies as necessary.

Make sure all pages which require a signature have been signed.

Make photocopies or use extra paper as necessary.

Attach any extra papers to the end of the packet.

The court has a self-help center that can review this packet with you. They are located in the Law Library at 1415 Truxtun Ave., 3 rd floor, Bakersfield and in the Family Law Facilitator office at 1215 Truxtun Ave., 1st floor, Bakersfield. Please visit and register on-line at: Email: WMSelfHelp@kern.courts.ca.gov

https://www.kern.courts.ca.gov/self-help/self-help-center

Subject Child(ren) Information Case Number:

*Make additional copies as necessary – Attach additional copies to back of packet*
Child

Legal name of child (as on birth certificate):

Name child is known by: Date of birth:

Place of birth: Current age: Sex:

Name of child’s doctor: Telephone:

Current health problems:

Date of last examination: Is child in counseling?

Counselor’s name: Telephone:

Name of school: Address:

Grade: Teacher’s name:

Are there special educational needs? Yes No If yes, please explain:

Is the child subject to any legal custody orders? Yes No If yes, please explain:

Child

Legal name of child (as on birth certificate):

Name child is known by: Date of birth:

Place of birth: Current age: Sex:

Name of child’s doctor: Telephone:

Current health problems:

Date of last examination: Is child in counseling?

Counselor’s name: Telephone:

Name of school: Address:

Grade: Teacher’s name:

Are there special educational needs? Yes No If yes, please explain:

Is the child subject to any legal custody orders? Yes No If yes, please explain:

Adopted for Mandatory Use KRN SUP CRT PB 8524 (Eff. GUARDIANSHIP QUESTIONNAIRE Page 1 of 9 01/01/20) Event Code 8524 (Rev. 3/2023)

Legal/Birth Mother: Make additional copies as necessary – Attach additional copies to back of packet

Full Name: Mother of:

Age: Date of birth or approximate date of birth:

Other names she uses or has used, including nicknames:

Residence:

Telephone: Other contact number:

Does the mother visit the child(ren): Explain:

Has the mother provided any financial support for the child(ren)? Yes No

If yes, how much? Date of payments:

Is mother in agreement with the guardianship? Explain:

Legal/Birth Father: Make additional copies as necessary – Attach additional copies to back of packet

Full Name: Father of:

Age: Date of birth or approximate date of birth:

Other names he uses or has used, including nicknames:

Residence:

Telephone: Other contact number:

Does the father visit the child(ren): Explain:

Has the father provided any financial support for the child(ren)? Yes No

If yes, how much? Date of payments:

Is father in agreement with the guardianship? Explain:

Adopted for Mandatory Use KRN SUP CRT PB 8524 (Eff. GUARDIANSHIP QUESTIONNAIRE Page 2 of 9 01/01/20) Event Code 8524 (Rev. 3/2023)

Guardian’s Information

If there are multiple petitioners/guardians, each one must complete and sign pages 3 thru 8

Make additional copies as necessary – Attach additional copies to back of packet

Relationship to subject child(ren):

Current physical location of child(ren):

How long have you known the child(ren):

Briefly explain the circumstances that led to this proceeding and why the child(ren) should be in your care:

Legal name: Other names used:

Any other names you use or have used, including nicknames:

Social Security #: License or ID #: State:

Date of birth: Place of Birth:

Race: Sex:

Height: Eye Color: Hair Color:

Language(s) Spoken:

Address: City: Zip:

Mailing address if different:

Best phone number to call: Message phone #:

Your email address:

** Please Notify Family Court Services Of Any Changes To Your Address Or Phone Numbers **

Education:

Highest grade completed: Where:

List any additional training or education:

Employment:

Employer Name: Job Title:

Employer’s Address:

May we contact you at work? Yes No

Employer’s phone #: Length of employment:

Current working schedule:

Adopted for Mandatory Use KRN SUP CRT PB 8524 (Eff. GUARDIANSHIP QUESTIONNAIRE Page 3 of 9 01/01/20) Event Code 8524 (Rev. 3/2023)

Military Service:

Branch: Date and type of Discharge:

Marital History:

Number of previous marriages:

Date and place of current marriage:

List all of your Children: (Attach additional sheets if necessary)

Name Age Other parent’s name With whom do they live

Health:

Current health problems? Yes No If yes, please explain:

Mental Health History:

Have you ever been diagnosed with a mental health condition? Yes No If yes, give brief explanation:

Have you ever been hospitalized voluntarily or involuntarily for a mental health condition? Yes No

Have you ever been prescribed any medications for a mental health condition? Yes No

Substance Abuse History:

Do you currently use or have you ever used illegal drugs? Yes No If yes, please explain:

Adopted for Mandatory Use KRN SUP CRT PB 8524 (Eff. GUARDIANSHIP QUESTIONNAIRE Page 4 of 9 01/01/20) Event Code 8524 (Rev. 3.2023)

Do you drink alcohol? Yes No

Have you ever had an alcohol problem? Yes No If yes, please explain:

Child Protective Services History:
Have you ever been investigated by Child Protective Services? Yes No

Living Arrangements:

Number of people living in your current residence: Number of bedrooms:

Length of time at your current residence: years months Are you: Renting Buying Own

Accommodations for the child(ren):

Do you plan to remain in this location or are you looking for other accommodations? Explain:

All others living in the home (Adults and Children):
Name Age Relationship to the subject child(ren)

Financial:

Source if Income:
Monthly Income: Additional income:

Do you receive cash aid for the child(ren)? Yes No If no, will you be applying for cash aid? Yes No

Do the child(ren) have MediCal coverage? Yes No If no, will you be applying for coverage? Yes No

Adopted for Mandatory Use KRN SUP CRT PB 8524 (Eff. GUARDIANSHIP QUESTIONNAIRE Page 5 of 9 01/01/20) Event Code 8524 (Rev. 3/2023)

Additional Information:

Are you currently or have you previously been appointed a guardian? Yes No

If yes, provide name of child(ren), the date, the County where it was established and the case number:

Have you or anyone in your household ever been the subject of any type of a restraining order? Yes No

If yes, give brief explanation:

References:

Name Relationship to you:

Mailing Address:

Telephone Number: Email Address:

Name Relationship to you:

Mailing Address:

Telephone Number: Email Address:

Name Relationship to you:

Mailing Address:

Telephone Number: Email Address:

Adopted for Mandatory Use KRN SUP CRT PB 8524 (Eff. GUARDIANSHIP QUESTIONNAIRE Page 6 of 9 01/01/20) Event Code 8524 (Rev. 3/2023)

Informed Consent for Guardianship Evaluation

Evaluation Procedures- A Family Court Services’ Investigator will be gathering information from many sources, including but not limited to law enforcement, Child Protective Services, schools, day care, and our own observation of you, the child(ren) and others involved in this case. The Release of Information form will provide us with access to medical, school, legal, and other information related to the issues under investigation. Evidence- Any evidence you provide to the investigator will be destroyed upon completion of the investigation and filing of the report. It is your responsibility to file any evidence with the court in accordance with the rules of court if you want it to be considered by the court. Confidentiality- Quite simply, within the process, there is no confidentiality. We may share information one party tells us with the other party or ask you questions about what we hear from a party, child(ren), or a collateral source. We will inform the child(ren) their statements may not be confidential, though we

may inform you, your attorneys, and the court if we believe it is in the best interest of the child(ren) to protect that confidentiality.

**Please note that California state law requires reporting to the appropriate agencies in cases where there is reasonable suspicion of child abuse, elder abuse, stated intention to injure another person and/or imminent danger of harming yourself. Fees- Pursuant to California Probate Code 1513.1, the court has the authority to assess fees for court expenses incurred for any investigation or review conducted by the court investigator. The cost of the evaluation will be based upon the number of hours needed to complete the investigation and prepare the report at an hourly rate of $90.00 plus administration fees and mileage. These costs will be included in the report. Fees may be waived by the investigator or the court. Recommendations- A written report will be prepared and filed with the Court. Please be aware, it will always be based the investigators analysis of all of the evaluation data and what they believe to be in the best interest of the child(ren). Confidentiality of the Report- Pursuant to California Probate Code §1513(d) all reports authorized by this section are confidential and shall only be made available to persons who have been served in the proceedings or their attorneys. Complaints- If you have a concern or a complaint regarding the Investigator assigned to your case, you

may contact Patricia Arredondo, Manager of Family Court Services, at 1215 Truxtun Avenue, 3 rd Floor, Bakersfield, CA 93301, Email: FCS@kern.courts.ca.gov Consent- I have read and understand this Consent for Guardianship Evaluation, and expressly consent to allow the Kern County Superior Court, and its agents and employees, to conduct an evaluation. I hereby declare under penalty of perjury that all information I have submitted is true and correct.

Date: Print Name:

Signature:

Case Number:

Adopted for Mandatory Use KRN SUP CRT PB 8524 (Eff. GUARDIANSHIP QUESTIONNAIRE Page 7 of 9 01/01/20) Event Code 8524 (Rev. 5/2023)

SUPERIOR COURT OF CALIFORNIA Family Court Services COUNTY OF KERN 1215 Truxtun Avenue, 3 rd Floor Patricia Arredondo, LCSW Bakersfield, California 93301 Manager of Family Court Services Telephone: (661) 610-6700 Mediation & Investigation Fax: (661) 688-7412 Email: FCS@kern.courts.ca.gov

RELEASE OF INFORMATION

I, , as
(Print name) (Relationship to child)

specifically authorize any public agency, private person, employer or past employer, medical
doctor, psychologist, treating therapist, hospital, public or private school districts (including
teacher) possessing information about me or the minor child(ren), including psychiatric
information, confidential or otherwise, to release same (including copies) to the Kern County
Superior Court through its duly appointed Court Investigator, such information to be used as
the Court may deem fit and proper. I understand that Family Court Services will conduct a
criminal and Child Protective Services’ background check on me in the course of this
investigation.

A copy of this release shall be as valid as the original.

This release shall remain in effect for one year from this date unless otherwise revoked.

Date: Print Name:

Signature:

Case Number:

Adopted for Mandatory Use KRN SUP CRT PB 8524 (Eff. GUARDIANSHIP QUESTIONNAIRE Page 8 of 9 01/01/20) Event Code 8524 (Rev. 3.2023)

Background Information

This page must be completed by all other persons, 18 years or older, who live in the home. NOT THE GUARDIAN(S)

Make additional copies if Case Number:

Your full legal name:

Any other names you have used, including maiden name:

Your relationship to the child(ren):

Your Street Address:

City: Zip Code:

Best phone number to call: Message phone #:

Mailing Address if different:

Social Security #: Date of Birth:

Sex: Race: Height: Eye Color:

Hair Color: Driver’s License or ID #: State:

Place of Birth:

Place of Employment:

I have a:(circle) Social Worker Probation Officer Parole Officer None

Their name and telephone number is:

I understand that a Kern County Superior Court Investigator will perform a criminal background check on me as part of the guardianship investigation. I understand that the purpose of the investigation is to make recommendations to the court regarding whether a guardianship is necessary and in the best interest of the subject child(ren).

I certify under penalty of perjury that the information I have provided is true and correct.

Date: Signature:

Printed Name:

Adopted for Mandatory Use KRN SUP CRT PB 8524 (Eff. GUARDIANSHIP QUESTIONNAIRE Page 9 of 9 01/01/20) Event Code 8524 (Rev. 3/2023)