Madera — Guardianship Mediation Intake/Questionnaire (MAD-FCS-011)

Source: https://www.madera.courts.ca.gov/system/files/forms-and-filings/mad-fcs-011-guardianship-mediation-intake-questionnaire-rev-04-15-2020.pdf

STATE OF CALIFORNIA MADERA SUPERIOR COURT Family Court Services GUARDIANSHIP MEDIATION 200 South G Street INTAKE/QUESTIONNAIRE Madera, CA, 93637 PH #: (559) 416-5560 FAX #: (559) 673-8216 CASE #: __________________ NEXT COURT DATE: __________ FCS #: __________________

SECTION 1: GUARDIAN INFORMATION: 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:

*NOTE: REPORTS WILL BE E-MAILED TO YOU AT THE E-MAIL ADDRESS YOU PROVIDE ABOVE. NAME OF EMPLOYER: (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: NATURAL MOTHER’S INFORMATION (FILL OUT AS BEST YOU CAN): PARENT’S NAME (Last, First): ADDRESS OF NATURAL PARENT: CITY: STATE: ZIP CODE:

DATE OF BIRTH: TELEPHONE #: EMAIL ADDRESS:

NAME OF EMPLOYER: (if unemployed write “unemployed”) WORK SCHEDULE EACH DAY (start time and end time): SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

SECTION 3: NATURAL FATHER’S INFORMATION (FILL OUT AS BEST YOU CAN): PARENT’S NAME (Last, First): ADDRESS OF NATURAL PARENT: CITY: STATE: ZIP CODE:

DATE OF BIRTH: TELEPHONE #: EMAIL ADDRESS:

NAME OF EMPLOYER: (if unemployed write “unemployed”) WORK SCHEDULE EACH DAY (start time and end time):

MAD-FCS-011 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 1

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

SECTION 4: 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 visitation order? Yes No If Yes, what is it? ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. Do you want the current visitation plan to change? Yes No If yes, please answer the following: a. I want to change the schedule of when the child/ren spends time with each parent to:____________________ ___________________________________________________________________________________________ 4. If you want the current visitation plan to change, how would your proposed changes benefit the child/ren? ___________________________________________________________________________________________ ___________________________________________________________________________________________ SECTION 5: INVOLVEMENT BETWEEN THE NATURAL PARENT AND CHILD/REN (DO NOT LEAVE BLANK): a. What has been your/the natural parent(s) involvement regarding the care of the child/ren? ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

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) been involved with your family for allegations of child abuse or neglect? Yes No If yes, when and what was the outcome?_____________________________________________

SECTION 7: INFORMATION ABOUT YOUR CURRENT BOYFRIEND, GIRLFRIEND, OR SPOUSE: Full name: Date of birth: Social Security #:

Other names used: Driver’s license #/State: Date relationship began:

MAD-FCS-011 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 2

Home phone number: Cell phone number: Occupation:

Present employer: Employer’s phone #: Days/Hours worked:

SECTION 8: ADDITIONAL INFORMATION

MAD-FCS-011 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 3