Santa Clara — FM-1039*

Source: https://santaclara.courts.ca.gov/system/files/forms/fm-1039_rem.pdf

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA

FAMILY COURT SERVICES PARENT SURVEY

Family Court Services is asking for your feedback so that we can do a better job serving families. Please do NOT identify yourself. The information you provide is anonymous and will NOT affect your case. Please complete this form once you have completed your participation in the Custody Pilot Project or the Traditional mediation, assessment, or evaluation process. Thanks in advance for your help.

1. Your relationship to the child:

   Female Parent Male Parent Legal Guardian Other (please specify):

2. Ethnicity: List

3. Please check any of the following issues that were present in your case:

   Domestic Violence Drugs or alcohol Child abuse

4. The reception and telephone staff were:
   Select one from each column
   very courteous/respectful very helpful
   courteous/respectful helpful
   discourteous/disrespectful unhelpful
   very discourteous/disrespectful very unhelpful

5. Any written materials I received from Family Court Services were:

   very helpful helpful unhelpful very unhelpful

6. If the service received most recently was mediation, did you reach either a temporary or long term
   agreement on the custody and visitation issues? Yes No

7. Name of the Family Court Services Mediator/Investigator providing the above service:

8. Gender of Mediator/Investigator: Male Female

   Ethnicity of Mediator/Investigator. List:

9. The Mediator/Investigator explained the procedure to me:

   very clearly clearly unclearly very unclearly

10. I felt the Mediator/Investigator listened to me:

    strongly agree agree disagree strongly disagree

11. I felt the Mediator/Investigator understood the points I was trying to make even though he or she may not have

    agreed with me:

    strongly agree agree disagree strongly disagree

This is NOT a complaint form. If you wish to register a complaint regarding how Family Court Services handled your case, you may obtain a complaint form from our clerical staff.

FM-1039 REV 10/01/08 Page 1 of 2

12. I believe the Mediator/Investigator spent enough time on my case.

    strongly agree agree disagree strongly disagree

13. I believe the service was provided in a (Select one in each column) manner:

    very fair very helpful very professional very unbiased
    fair helpful professional unbiased
    unfairunfair unhelpfulunhelpful unprofessional biased
    very unfair very unhelpful very unprofessional very biased

14. I did not feel overly pressured by the Mediator/Investigator to go along with things I did not want.

    strongly agree agree disagree strongly disagree

15. How satisfied or dissatisfied are you with the service you received in Family Court Services?

    very satisfied satisfied dissatisfied very dissatisfied

16. The service was provided in a manner that it preserved self-determination even though I did not “get” everything I wanted.

    strongly agree agree disagree strongly disagree

17. The result of the service produced an agreement or recommendation that is likely to be safe and good for the child(ren), and safe for the family members.

    strongly agree agree disagreedisagree strongly disagree

If the service received most recently was an emergency screening, assessment, recommendation or evaluation which resulted in a recommendation by the investigator:

I agreed with all or most of the recommendation, and was willing to have it presented to the court for
approval with no, or only minor, changes.

I disagreed with an important part of the recommendation and did not want it submitted to the court
without important changes.

I believe the investigation was:

very thorough thorough adequate very inadequate

18. The most helpful thing about the service was:

19. The most unhelpful thing about the service was

20. Other comments or suggestions:

This is NOT a complaint form. If you wish to register a complaint regarding how Family Court Services handled your case, you may obtain a complaint form from our clerical staff.

FM-1039 REV 10/01/08 Page 2 of 2