San Bernardino — 13-19740-360

Source: https://sanbernardino.courts.ca.gov/system/files/13-19740-360terminationofguardianship-parentquestionnaire.pdf

COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO Probate Division 247 West Third Street San Bernardino, CA 92416-0212

Termination of Guardianship Parent Questionnaire

Guardianship of the: Person Estate Confidential

Case Number:

Case Name:

NOTICE TO PARENT

Please be advised the information provided on this questionnaire will be used to conduct a full and complete investigation of applicant’s background. The results of the investigation and relationship histories will be fully reported to the court.

Regarding Termination of Guardianship of (list all minors’ names):

1. 4.

2. 5.

3. 6.

I give the Court Investigator’s Office authority to release any information in its files to the Guardianship Court Investigator’s Office. This information may include school records, medical records, employment records or psychological records.

The Guardianship Court Investigator’s Office utilizes this information to complete its required investigation in connection with my petition for termination of guardianship of a minor child.

I have read and understand the above conditions and agree to them.

PRINT NAME OF PARENT SIGNATURE OF PARENT Date

13-19740-360 TERMINATION OF GUARDIANSHIP – PARENT QUESTIONNAIRE Page 1 of 8 Revised 6-28-16 Mandatory Probate Code §1601

MINOR’S INFORMATION (ATTACH ADDITIONAL PAGE IF NECESSARY)

Minor 1
Name: Race/Ethnicity:
Date of Birth: Age: Place of Birth:
Address:
With whom does the minor currently reside?
Date Guardianship was Granted: Relationship to Petitioner:

Has the minor ever had involvement with law enforcement? Yes No If yes, explain:

Does the minor have a history of mental health issues/impairments? Yes No If yes, explain:

Minor 2

Name: Race/Ethnicity:
Date of Birth: Age: Place of Birth:
Address:
With whom does the minor currently reside?
Date Guardianship was Granted: Relationship to Petitioner:

Has the minor ever had involvement with law enforcement? Yes No If yes, explain:

Does the minor have a history of mental health issues/impairments? Yes No If yes, explain:

Minor 3
Name: Race/Ethnicity:
Date of Birth: Age: Place of Birth:
Address:
With whom does the minor currently reside?
Date Guardianship was Granted: Relationship to Petitioner:

Has the minor ever had involvement with law enforcement? Yes No If yes, explain:

Does the minor have a history of mental health issues/impairments? Yes No If yes, explain:

13-19740-360 TERMINATION OF GUARDIANSHIP – PARENT QUESTIONNAIRE Page 2 of 8
Revised 6-28-16 Mandatory Probate Code §1601

PARENT’S INFORMATION I am the: Mother Father

PERSONAL INFORMATION

Your Full Name: Maiden Name:

Aliases:

Language(s) Spoken (including sign language):

Race/Ethnicity:

Age: Date of Birth: Place of Birth:

Social Security Number: Driver’s License Number:

HOME

Address:

How long at present residence? Rent Own

If you have lived at this address for less than five years, please list your previous addresses:

Telephone: ( ) TDD Mobile Phone: ( )

Do you have any guns or other weapons stored on the property? Yes No

If yes, what type(s) of weapon(s)?

Describe where and how you store the weapon(s)?

EDUCATION

Highest Grade Completed: Graduated High School? Yes No

License(s) or Credential(s) Received:

College Degree(s) Received:

EMPLOYMENT Please bring confirmation of employment, including pay stubs, to the investigation interview.

Employer Name: Phone: ( )

Employer Address:

Job Title: Length of Service:

Supervisor’s Name: Supervisor’s Phone Number: ( )

Who cares for the children if adults are employed outside of the home?

HEALTH

Name of your Health Insurance Plan:

Present health status: Good Fair Poor If your health is fair or poor, please explain:

13-19740-360 TERMINATION OF GUARDIANSHIP – PARENT QUESTIONNAIRE Page 3 of 8
Revised 6-28-16 Mandatory Probate Code §1601

Are you taking any medication? Yes No If yes, what kind and for what reason(s)?

If you have any special health problems, please explain:

If you have any mental/emotional problems, please explain:

Have you ever used drugs or alcohol? Yes No If yes, provide details below:

LAW ENFORCEMENT INFORMATION

Have charges ever been filed against you for crimes other than minor traffic citations? Yes No

If yes, please explain:

Charge City/State Date

Are you on parole or probation? Yes No

Parole or Probation Officer’s Name Phone Number ( )

Have you filed a restraining order, or have you had a restraining order filed against you? Yes No

If yes, please explain:

Have you or anyone living in your home ever been accused of child abuse or child molestation?

Yes No If yes, please explain:

Have you had previous involvement with Child Protective Services? Yes No

If yes, please explain the circumstances in detail (attach an additional page if necessary):

Details County/State Date

Has the minor been exposed to domestic violence? Yes No

If yes, please explain:

13-19740-360 TERMINATION OF GUARDIANSHIP – PARENT QUESTIONNAIRE Page 4 of 8 Revised 6-28-16 Mandatory Probate Code §1601

Other Children Living In Your Home under the Age of 18 (ATTACH ADDITIONAL PAGE IF NECESSARY)

Name Relationship Date of Birth Place of Birth Grade Developmental Disabilities
Level

Other Adults Living In Your Home over the Age of 18 (ATTACH ADDITIONAL PAGE IF NECESSARY)

Name Driver’s License Social Security Date of Birth Relationship to Child Criminal
Number you Protective History
Services
History

Does any adult in the home have any problem that could affect the minor(s), for example, child abuse/molestation, criminal background, violent behavior, or alcohol or drug use? Yes No

If yes, explain:

Is there a custody or visitation order for the minor(s)? Yes No

Date of Order: Case Number:

Where did the proceeding take place? County: State:

MARRIAGE AND CHILDREN

Marital Status: Married Widowed Single Divorced

If currently married or separated, what is the name of your spouse?

Name of any previous spouse:

Date of divorce or death ending the marriage:

Name your children, even if they are adults and not living with you (attach additional sheet if necessary). Name/Relationship of adult Child’s Name Birth Date Address with whom child lives

13-19740-360 TERMINATION OF GUARDIANSHIP – PARENT QUESTIONNAIRE Page 5 of 8 Revised 6-28-16 Mandatory Probate Code §1601

SPOUSE’S INFORMATION Not applicable

PERSONAL INFORMATION

Spouse’s Full Name: Maiden Name:

Aliases:

Language(s) Spoken (includes sign language):

Race/Ethnicity:

Age: Date of Birth: Place of Birth:

Social Security Number: Driver’s License Number:

Telephone: ( ) TDD Mobile Phone: ( )

EMPLOYMENT Please bring confirmation of employment, including pay stubs, to the investigation interview.

Employer Name: Phone: ( )

Employer Address:

Job Title: Length of Service:

HEALTH

Present health status: Good Fair Poor

Does your spouse take any medication? Yes No

Does your spouse have any Special Health Problems? Yes No

Does your spouse have any Mental/Emotional Problems? Yes No

Has your spouse ever used drugs or alcohol? Yes No

LAW ENFORCEMENT INFORMATION

Have charges ever been filed against your spouse for crimes other than minor traffic citations? Yes No

Is your spouse on parole or probation? Yes No

Parole or Probation Officer’s Name Phone Number ( )

Has your spouse had previous involvement with Child Protective Services? Yes No

13-19740-360 TERMINATION OF GUARDIANSHIP – PARENT QUESTIONNAIRE Page 6 of 8
Revised 6-28-16 Mandatory Probate Code §1601

GUARDIANSHIP INFORMATION

Explain why the guardianship was needed when it was established (be specific).

Why is the guardianship no longer necessary? Be specific about what efforts you made to resolve the problems that led to the need for the guardianship. For example, if you had a drug problem, please tell us the name of the program you attended or completed.

Why is it in the best interests of the minor(s) to end the guardianship? How would they benefit or be better off after the termination?

Please describe the amount of contact you have had with the minor(s) since the guardianship was established.
For example, how often did you visit and for low long (e.g., for the day or overnight)?

Please describe how your visits have been with the minor(s). Describe any problems that have arisen and how
you have resolved them.

13-19740-360 TERMINATION OF GUARDIANSHIP – PARENT QUESTIONNAIRE Page 7 of 8
Revised 6-28-16 Mandatory Probate Code §1601

If the minor has any developmental, emotional or psychological needs, please explain and describe your plan to meet the minor’s needs.

Please describe your methods of disciplining the minor(s).

Have you attended a parenting class? If so, please provide the name of the class and date you completed it.

REFERENCES

Give name, address and telephone number of two (2) non-related references who have knowledge of your home life
and standing in the community.

NAME ADDRESS TELEPHONE NUMBER OCCUPATION

I declare under penalty of perjury under the laws of the State of California that the foregoing is
true and correct

PRINT NAME OF PARENT OR APPLICANT SIGNATURE OF PARENT OR APPLICANT Date

13-19740-360 TERMINATION OF GUARDIANSHIP – PARENT QUESTIONNAIRE Page 8 of 8
Revised 6-28-16 Mandatory Probate Code §1601