Madera — Mediation Intake/Questionnaire (MAD-FCS-008)

Source: https://www.madera.courts.ca.gov/system/files/forms-and-filings/mad-fcs-008-mediation-intake-questionnaire-rev-10-09-2020.pdf

STATE OF CALIFORNIA MADERA SUPERIOR COURT Family Court Services MEDIATION INTAKE / QUESTIONNAIRE 200 South G Street Madera, CA 93637 PH #: (559) 416-5560 FAX #: (559) 673-8216 CASE #:___________________ NEXT COURT DATE: __________ FCS #: _______________ REFERRAL: Mediation (1st free; child interviews $100/parent) Mediation Re-referral or Review ($100 per parent)

SECTION 1: YOUR NAME: YOUR NAME (Last, First, Middle): EMAIL ADDRESS (PRINT CLEARLY):

DATE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX #:

TELEPHONE #: HOME ADDRESS: CITY: STATE: ZIP CODE:

MAILING ADDRESS IF DIFFERENT THAN HOME ADDRESS: (IMPORTANT YOU INCLUDE TO RECEIVE CORRESPONDENCE)`

Does the other parent know where you live? Yes No NOTE: REPORTS WILL BE E-MAILED TO YOU AT THE E-MAIL ADDRESS YOU PROVIDE ABOVE NAME OF EMPLOYER OR (IF UNEMPLOYED, WRITE “UNEMPLOYED”): WORK SCHEDULE EACH DAY (start time and end time): SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

Who watches the child/ren when you are unavailable? Please give their name and telephone #:

SECTION 2: OTHER PARENT’S INFORMATION (FILL OUT AS BEST YOU CAN): OTHER PARENT’S NAME (Last, First): ADDRESS OF OTHER PARENT: CITY: STATE: ZIP CODE:

DATE OF BIRTH: TELEPHONE #: ADDRESS WHERE THE OTHER PARTY WAS SERVED:

SECTION 3: CONCERNS AND PROPOSALS 1. What are the top three most important concerns you would like to discuss with Family Court Services? ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. Is there a current court order? Yes No 3. Whether there is a court order or a verbal agreement only between you and the other party, please answer the following: a. According to the current parenting plan, who is supposed to make major decisions about the child(ren)’s health, education and welfare? _______________________________________________________________________________________

b. According to the current parenting plan, who is the child supposed to live with?

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c. According to the current parenting plan, when is the child/ren supposed to spend time with each parent? _____________________________________________________________________________________ 4. Do you want the current parenting plan to change? Yes No IF YES, please answer the following: a. I want to change major decisions (health, education and welfare) to: _________________________________ b. I want to change who the child/ren live with to:___________________________________________________ _______________________________________________________________________________________ c. I want to change the schedule of when the child/ren spends time with each parent to:____________________ _______________________________________________________________________________________ 5. If you want the current parenting plan to change, how would your proposed changes benefit the child/ren? ___________________________________________________________________________________________ ___________________________________________________________________________________________ SECTION 4: CHILD/REN’S INFORMATION (FILL OUT ALL INFORMATION AS BEST YOU CAN) NAME: (First) (Last) DOB GRADES (A’s, B’s?) / ATTENDANCE: THIS CHILD HAD COUNSELING? Yes No Yes No Yes No Yes No SECTION 5: ABOUT THE OTHER PARENT (DO NOT LEAVE BLANK): 1. What are the other parent’s strengths as a parent? ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. What are the other parent’s weaknesses as a parent? ________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. Has the other parent ever been in counseling or had substance abuse issues? Yes No IF YES, when and for what issue(s)?_____________________________________________________________________________ ___________________________________________________________________________________________ 4. Has the other parent ever been arrested? Yes No IF YES, when and for what charge(s)?__________________________________________________________________________________ ___________________________________________________________________________________________ SECTION 6: YOUR INVOLVEMENT IN COUNSELING, THE COURTS AND CPS 1. Have you ever been in counseling or had substance abuse issues? Yes No IF YES, for what issue(s)? ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. Have you ever been arrested? Yes No IF YES, when and for what charge(s)? ______________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. Has Child Protective Services (CPS) ever been involved with your family for allegations of child abuse or neglect? Yes No IF YES, when and what was the outcome?__________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

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STATE OF CALIFORNIA MADERA SUPERIOR COURT Family Court Services CONFIDENTIAL DOMESTIC VIOLENCE QUESTIONNAIRE 200 South G Street Revised February 2019 Madera, CA 93637

NAME: _____________________________________________

Pursuant to California Code Family Code §3181, 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.

THESE QUESTIONS APPLY TO YOU AND THE OTHER PARENT ONLY:

1. When did you and the other parent separate? _______________________
2. Has there ever been domestic violence involving you and the other parent? Yes No IF YES, when did the domestic violence occur? Within the past year 1 to 5 years ago More than 5 years ago
3. If there has been domestic violence over the past year, have the frequency of incidents: Decreased Increased Remained the same
4. Is there a current protective order or restraining order? Yes No a. IF YES, what kind? Criminal Stay away Peaceful Contact Allowed b. When does the protective order or restraining order expire? ___________________________________
5. If there has been domestic violence, has the other parent done or threatened to do any of the following to you: Pushing, shoving, grabbing or restraining you? Yes No Slapping you with an open hand? Yes No Hitting with a closed hand or fist? Yes No Pulling your hair? Yes No Physically dragging or throwing you? Yes No Biting or kicking you? Yes No Hitting you in the head, face or elsewhere? Yes No Using an object to hit you? Yes No Choking, strangulating or smothering you? Yes No Disabling or withholding your phone? Yes No Following you or having someone else do so? Yes No Were any weapons ever involved? Yes No Demanding knowledge of your whereabouts? Yes No Are there any police reports? Yes No Keeping you away from family or friends? Yes No Disabling your car; withholding keys? Yes No
6. Were the children present for any domestic violence incident? Yes No
7. Did you ever seek medical attention because of domestic violence? Yes No
8. Are there any police reports regarding domestic violence between you and the other parent? Yes No
9. Has the other parent ever threatened to harm the child/ren? Yes No
10. Has the Court ever ordered the other parent to complete a batterer’s treatment program? Yes NNo Don’t know
11. Have you been “warned” by the other parent not to say certain things during mediation? Yes No
12. Are you afraid of the other parent for any reason? Yes No
13. Are you concerned there will be future incidents of domestic violence with the other parent? Yes No

I declare under penalty of perjury that the answers to the questions above are correct to the best of my knowledge.

Signature: _______________________________________ Date: _____________________________________

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