San Benito — SB-FCSM-1

Source: https://www.sanbenito.courts.ca.gov/system/files/sbfcsm1.pdf

INTRODUCTION TO MEDIATION SAN BENITO COUNTY FAMILY COURT SERVICES This CONFIDENTIAL information is for the mediation office only and will not be given to the other parent.

The purpose of mediation is to develop a plan that ensures that children have a good relationship and lots of time with each parent.

Mediation Guidelines: • Treat all people and topics with respect. • Each person has a right to speak and be heard. • Be as honest as you can.

Steps:

1. The mediator asks each person to talk about the situation and speak directly to the mediator at first.

2. The mediator invites the parents to talk directly with each other.

3. Parents are asked to listen carefully and be able to say back what they heard the other person say.

4. Parents offer ideas to build a plan that will work for the children and for each parent.

5. Parents choose the ideas they agree about.

Confidentiality: Everything discussed in mediation is confidential. This means: a. No information from mediation is given to the court. b. No recording of any kind is allowed. c. No other person may be present or able to overhear the conversation. d. No communication with the other party or anyone else while we are having the conversation. Exceptions: The Mediator is required to report: a. To the other parent: Health risks associated with Covid-19. b. To agencies: Child abuse or threats of violence.

I understand and accept the guidelines. I also understand and agree to comply with the confidentiality requirement.

Print Name: ___________________________________________________________

Signature _____________________________________________ Date____________

PARENT INFORMATION INTAKE SAN BENITO COUNTY FAMILY COURT SERVICES This CONFIDENTIAL information is for the mediation office only and will not be given to the other parent or to the court. TODAY’S DATE: NEXT COURT DATE: YOUR CASE # YOUR NAME: o Petitioner o Respondent DATE OF BIRTH : OTHER LAST NAMES USED: PHONE #: EMAIL ADDRESS: ADDRESS: Street City State Zip EMPLOYER: OCCUPATION: WORK SCHEDULE: NAMES OF OTHER ADULTS IN YOUR HOME: RELATIONSHIP TO YOU: 1. 2 3. Have you been in mediation regarding care of your child(ren) before? Where (County)? When?

Do you have an attorney? Name Phone number

Other parent’s name: Last time you lived with them: Who are the children (under 18) this mediation will be about? First and last name Age Date of Birth Sex School Time with each parent

SPECIAL NEEDS OF CHILDREN: medical/dental, educational, counseling:

When was the last time you saw your child(ren)? Other children in your home for any length of time: Name Age Name Age

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YesYes NoNo

1. Do you plan to move in the next six months? ............................................................................................................. o o If so, when and where? _________________________________________________________________________

2. Do you have another case in Family Court Services? ................................................................................................. o o If yes, name of the other parent /County: ________________________________________________________

3. Have you ever feared you would not be able to see your children? ......................................................................... o o

4. Do you have any concerns regarding the use of alcohol and/or drugs by family members? .............................. o o

5. Have there ever been any physical confrontations between you and the other parent? ....................................... o o If yes, give the date of most recent physical confrontation. Please describe the physical confrontation.

6. Were the children present or able to see or to hear it? ............................................................................................... o o

7. Have there ever been threats of the use of weapons against either of you parents or your children? ................ o o If yes, describe the incident including the names of the people involved.

8. Have you ever asked for a restraining order against the other parent? ................................................................... o o If yes, in what state and county? _________________________________________________________________

9. Has the other parent ever been abusive to any other family member? .................................................................... o o

10. Has the other parent ever been abusive to a family pet or other animal? ............................................................. o o

11. Has there ever been a criminal domestic violence case against the other parent? ................................................. o o If so, in what state and county: __________________________________________________________________

12. Do you have any concerns about your own physical safety? .................................................................................. o o

13. Do you believe that you are considered an equal partner with the other parent? .................................................. o o

14. Has any adult ever used physical punishment on your child? ................................................................................. o o If so, who punished the child ?__________________________________________________________________________ When did this occur? Please describe the incident(s).

15. Has Child Welfare Services investigated abuse of any of your children? ................................................................ o o For which children? Please describe.

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Yes No 16. Have you ever been arrested as an adult? ................................................................................................................... o o If yes, answer the following: What State? ________________________________________ County? __________________________________________ What charges? _________________________________________________________________________________________ 17. Are there any criminal actions pending against you or any adult in frequent contact with the child(ren)? ...... o o If yes, answer the following: Name of the adult ______________________________________________________________________________________ What State? _________________________________________ County __________________________________________ What charges? _________________________________________________________________________________________ 18. Do you have a current PROTECTIVE ORDER of any kind? ...................................................................................... o o 19. RIGHT TO SEPARATE SESSIONS: If a party alleges 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. DO YOU WISH TO BE SEEN SEPARATELY? .............................................................................................................. o o 20. 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 WISH TO HAVE A SUPPORT PERSON ACCOMPANY YOU IN MEDIATION? ................................. o o 21. Please briefly describe any other safety-related issues affecting any child or adult involved in this case:

I declare that the information on this form is true and correct and that this declaration is executed on the date listed:

SIGN

Signature ________________________________________________________ Date______________

Send Form CLEAR FORM

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