Madera — Grandparent/ Stepparent Mediation Intake/Questionnaire (MAD-FCS-010)

Source: https://www.madera.courts.ca.gov/system/files/forms-and-filings/mad-fcs-010-grandparent-stepparent-mediation-intake-questionnaire-rev-04-15-2020.pdf

STATE OF CALIFORNIA MADERA SUPERIOR COURT Family Court Services GRANDPARENT/STEPPARENT 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: 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)`

What is your relationship to the child?

NOTE: REPORTS WILL BE E-MAILED TO YOU AT THE E-MAIL ADDRESS YOU PROVIDE ABOVE SECTION 2: OTHER PARTY/NATURAL PARENT(S) INFORMATION (FILL OUT AS BEST YOU CAN): NAME (Last, First): ADDRESS: CITY: STATE: ZIP CODE:

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

NAME (Last, First): ADDRESS: 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 plan, who is supposed to make major decisions about the child(ren)’s health, education and welfare? _______________________________________________________________ b. According to the plan, who does the child(ren) live with? _____________________________________________________________________________________ MAD-FCS-010 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 1

c. According to the current plan, when is the child(ren) supposed to visit the Grandparent/Stepparent? _____________________________________________________________________________________ 4. 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 the Grandparent(s)/Stepparent to:_____________________________________________________________________________________ 5. If you want the current visitation 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 NATURAL PARENT(S)/GRANDPARENT(S)/STEPPARENT (DO NOT LEAVE BLANK): 1. What are their strengths? ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. What are their weaknesses? ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. Have the parents or other parties ever been in counseling or had substance abuse issues? Yes No IF YES, when and for what issue(s)? ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4. Have the parents/grandparents/stepparent ever been arrested? Yes No IF YES, WHO, 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?__________________________________________ ___________________________________________________________________________________________

MAD-FCS-010 Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 2