Madera — Guardianship Investigation Intake/Questionnaire (E- Version) (MAD-FCS-007)

Source: https://www.madera.courts.ca.gov/system/files/forms-and-filings/mad-fcs-007-guardianship-investigation-intake-rev-04-15-2020_1.pdf

State of California Madera Superior Court GUARDIANSHIP INVESTIGATION Family Court Services INTAKE/QUESTIONNAIRE 200 South G Street Madera, CA 93637 CASE #: ______________ FCS#: _____________ Court Date: ___________ PH #: (559) 416-5560 FAX #: (559) 673-8216

TYPE OF CASE: INITIAL GUARDIANSHIP GUARDIANSHIP TERMINATION SUCCESSOR GUARDIANSHIP NOTE: INVESTIGATION FEE OF $600 IS DUE FROM THE PETITIONER ON THE DAY OF THE APPOINTMENT

SECTION 1: PETITIONER’S INFORMATION NAME (Last, First, Middle): RELATIONSHIP TO CHILD: MAIDEN NAME: OTHER NAMES KNOWN BY:

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

HOME TEL. #: CELL TEL. #: E-MAIL ADDRESS: ((((((( )))) - ((((((( )))) - STREET ADDRESS: SOCIAL SECURITY #: DRIVER’S LICENSE # / STATE: ---- - / CITY: STATE: ZIP CODE: HOW LONG AT THIS ADDRESS? YEARS: MONTHS: SECTION 2: NATURAL FATHER’S INFORMATION NAME (Last, First, Middle) DO YOU OBJECT TO THE GUARDIANSHIP? OTHER NAMES KNOWN BY: Yes No DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX #:

HOME TEL. #: CELL TEL. #: E-MAIL ADDRESS: ((((((( )))) - ((((((( )))) - STREET ADDRESS: SOCIAL SECURITY #: DRIVER’S LICENSE # / STATE: ---- - / CITY: STATE: ZIP CODE: HOW LONG AT THIS ADDRESS? YEARS: MONTHS: SECTION 3: NATURAL MOTHER’S INFORMATION: NAME (Last, First, Middle) DO YOU OBJECT TO THE GUARDIANSHIP? OTHER NAMES KNOWN BY: Yes No DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX #:

HOME TEL. #: CELL TEL. #: E-MAIL ADDRESS: ((((((( )))) - ((((((( )))) - STREET ADDRESS: SOCIAL SECURITY #: DRIVER’S LICENSE # / STATE: ---- - / CITY: STATE: ZIP CODE: HOW LONG AT THIS ADDRESS? YEARS: MONTHS: SECTION 4: OBJECTING WITNESS INFORMATION NAME (Last, First, Middle) DO YOU OBJECT TO THE GUARDIANSHIP? OTHER NAMES KNOWN BY: Yes No DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX #:

HOME TEL. #: CELL TEL. #: E-MAIL ADDRESS: ((((((( )))) - ((((((( )))) -

MAD-FCS-007 ELECTRONIC Form Adopted for Mandatory Use Superior Court of Madera County [Rev. 04/15/2020] Page 1

SECTION 4: OBJECTING WITNESS INFORMATION (Continued)

STREET ADDRESS: SOCIAL SECURITY #: DRIVER’S LICENSE # / STATE: ---- - / CITY: STATE: ZIP CODE: HOW LONG AT THIS ADDRESS? YEARS: MONTHS: SECTION 5: CONCERNS AND PROPOSALS 1. Reasons for or against the guardianship petition: a. Petitioners: What are the top three most important reasons why you should be the Guardian of the child/ren? b. Natural Parents who do not object to the petition for guardianship: What are the top three reasons why each petitioner should be granted Guardianship of the child/ren? c. Natural Parents who object to the petition: What are the top three reasons why each petitioner should not be a Guardian of the child/ren?

d. Was Temporary Guardianship granted? Yes No
e. Whether there is a temporary guardianship in place or not, please answer the following questions regarding how things are
now:
a. At this time, who makes decisions about the child/ren’s health, education and welfare?

b. At this time, who does the child/ren live with?

c. At this time when do the children spend time with each parental figure?

f. Do you want to change how things are now? Yes No IF YES, please answer the following:
a. I want to change who makes decisions about the children’s 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 spend time with each parental figure to:

g. What has been your involvement regarding the care of the child/ren?

h. If you want the current parenting plan to change, how would your proposed changes benefit the children?

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SECTION 6: CONTACT WITH THE COURTS AND OTHER STATE AGENCIES A. CRIMINAL COURT – List all YOUR arrests in the last 10 years: DATE OF CHARGE(S): LAW ENFORCEMENT AGENCY: OUTCOME: ARREST:

1. Have YOU ever been court ordered to attend:
Batterer’s Intervention Program Drug Treatment Anger Management Counseling
2. Are you currently on Probation or Parole? Yes No
IF YES, please state the name, location and telephone number of your probation/parole officer:

3. Does anyone else currently living in your home have criminal arrests or convictions? Yes No
IF YES, please state the name of the person, dates of the arrests, charges and outcomes for all:

4. Have the OTHER parental figures ever been arrested? Yes No
IF YES, please state the dates of the arrests, charges and outcomes for all:

5. Does anyone else currently living in the other parent’s home have criminal arrests or convictions?
Yes No
IF YES, please state the dates of the arrests, charges and dispositions for all:

B. CHILD PROTECTIVE SERVICES: 1. Has Child Protective Services ever received a referral on you, the other parental figures or your children? Yes No IF YES, please state the dates of the arrests, charges and dispositions for all:

Name of Child: Date Investigated Concerns/Allegations Outcome of Investigation:

SECTION 7: INFORMATION ABOUT YOUR CURRENT BOYFRIEND, GIRLFRIEND, OR SPOUSE Full Name: Date of Birth: Social Security Number:

Other Names Used: Driver’s License #/State: Date Relationship Began: / Home Phone Number: Cell Phone Number: Occupation:

Present Employer: Employer’s Phone Number: Day/Hours Worked:

SECTION 8: EDUCATION AND EMPLOYMENT A. Education Level: GED High School Graduate College Courses Taken College Graduate Post Graduate Work 1. Are you currently employed? Yes No IF YES, please state the dates of the arrests, charges and dispositions for all:

2. How long have you been with your current employer? Year(s): Month(s):

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SECTION 8: EDUCATION AND EMPLOYMENT (Continued): 3. Current workdays and hours (please list what time you start work and what time you end work each day): SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

4. Please list your employment history over the past 5 years:

Date(s) of Name of Employer Telephone # Occupation Reason for Leaving Employment

5. Who takes care of the child(ren) while you are unavailable? Please provide their names and telephone #’s:

SECTION 9: MENTAL HEALTH HISTORY 1. Have you ever been hospitalized for psychiatric treatment? Yes No IF YES, please list in chronological order (by year) the therapists, counselors, clergy and/or marital counselors who you have gone to: Date Doctor/Therapist Name Complete Mailing Address Telephone #

2. Have you ever been in counseling or therapy? Yes No
IF YES, please list hospitals or clinics attended and the dates of treatment:
Date Hospital Name Complete Mailing Address Telephone #

3. Have you ever taken psychiatric medication? Yes No (for example, for depression, anxiety, etc.)
IF YES, please list the names of all medications and the name, telephone number and the complete mailing address of the
physician who prescribed the medication:

4. Has the other parent or petitioner ever been in counseling/therapy or hospitalized for psychiatric treatment?
Yes No
IF YES, please list the therapist, agency or hospital that provided the services and the dates of treatment:

5. Has the other parent or petitioner ever taken psychiatric medication? Yes No
IF YES, please list the names of all medications and the name, telephone number and the complete mailing address of the
physician who prescribed the medication:

SECTION 10: ALCOHOL AND SUBSTANCE ABUSE HISTORY 1. What kind(s) of alcohol do you drink? 2. How often do you drink? 3. Has your drinking ever been an issue between you and your family or friends? 4. Are you currently in or have you ever received treatment for alcohol abuse? Yes No IF YES, please check all applicable treatment: Counseling/Therapy Detox Rehab Inpatient Rehab Outpatient AA/NA 5. If a box was checked, please list in chronological order, the therapist/agency/hospital utilized: Date Therapist/Hospital Complete Mailing Address Doctor’s Phone #’s

6. Drug use history:
Name of Drug How Often Taken Age of First Use Date of Last Use

7. Prescription drug use history:
Name of Drug How Often Taken Prescribing Doctor Doctor’s Phone #’s

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SECTION 10: ALCOHOL AND SUBSTANCE ABUSE HISTORY (Continued): 8. Do you have a medical marijuana card? Yes No Expiration Date: 9. Have drugs or alcohol ever caused you to lose job? Yes No 10. Has your drug use ever been an issue between you and your family or friends? Yes No 11. Have you ever been court ordered for drug testing? Yes No 12. Were the results of the drug test(s) positive? Yes No If YES, for what: SECTION 11: CHILD(REN)’S INFORMATION Name of 1 st Child: Name of 2 nd Child: Who do they live with:Who do they live with: Child’s DOB: Age: Grade Level:Child’s DOB: Age: Grade Level: School/Daycare Name:School/Daycare Name: School/Daycare Address:School/Daycare Address: School/Daycare Telephone #:School/Daycare Telephone #: Teacher/Daycare Provider Name:Teacher/Daycare Provider Name: Principal’s Name:Principal’s Name: Pediatrician’s Name:Pediatrician’s Name: Pediatrician’s Address:Pediatrician’s Address: Pediatrician’s Phone #:Pediatrician’s Phone #: • Does this child presently have physical or emotional • Does this child presently have physical or emotional problems? Yes No problems? Yes No IF YES, what is the issue: IF YES, what is the issue:

• Is this child presently in individual counseling or children • Is this child presently in individual counseling or
of divorce group? Yes No children of divorce group? Yes No
Therapist’s Address/phone #:Therapist’s Address/phone #:
Therapist’s Phone #:Therapist’s Phone #:

Name of 3 rd Child: Name of 4 th Child: Who do they live with: Who do they live with: Child’s DOB: Age: Grade Level: Child’s DOB: Age: Grade Level: School/Daycare Name: School/Daycare Name: School/Daycare Address: School/Daycare Address: School/Daycare Telephone #: School/Daycare Telephone #: Teacher/Daycare Provider Name: Teacher/Daycare Provider Name: Principal’s Name: Principal’s Name: Pediatrician’s Name: Pediatrician’s Name: Pediatrician’s Address: Pediatrician’s Address: Pediatrician’s Phone #: Pediatrician’s Phone #: • Does this child presently have physical or emotional • Does this child presently have physical or emotional problems? Yes No problems? Yes No IF YES, what is the issue: IF YES, what is the issue:

• Is this child presently in individual counseling or • Is this child presently in individual counseling or children
children of divorce group? Yes No of divorce group? Yes No

Therapist’s Address/phone #: Therapist’s Address/phone #: Therapist’s Phone #: Therapist’s Phone #:

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SECTION 12: YOUR OPINION OF THE OTHER PARENTAL FIGURES 1. In what ways are the other parental figures a good parent?

2. In what ways are the other parental figures not a good parent?

3. What parenting responsibilities did the petitioner and each parent have in the past?

4. What is the other parental figures relationship with each child? (For example: Close, Strained, None, Needs Improvement, etc.)

5. Have the other parenting figures with each child changed over time? How has it changed?

6. What do the other parenting figures need to do to be a better parent?

SECTION 13: YOUR RELATIONSHIP WITH EACH CHILD 1. Please describe each child (check off those that apply): Additional pages attached if more than 1 minor a. Activity Level: High Energy Low Energy b. Attention: Able to Focus Easily Distracted c. Level of intensity when upset: Reacts Dramatically Becomes Quiet d. Gets Hungry or Tired: At Predictable Times At Unpredictable Times e. Response to Stimulation: Startles Easily to Sounds Remains Calm f. Appetite: Picky Eater Will Eat Anything g. Adaptability: Approaches New Situations Easily Takes a Long Time to Become Comfortable h. When Faced with Obstacles Child is: (Example: putting together a puzzle) Patient Gives Up Easily i. Mood in General: The child is positive & happy. The child focuses on the negative. 2. What does each child do well?

3. What kinds of problems does each child have (social, emotional, intellectual)?

4. What have you done to try to help each child with these problems?

5. Describe special interests and/or activities that you and each child share?

6. What kind of discipline works with each child?

7. When you and each child talk about the other parent, what do you say?

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SECTION 14: YOUR FAMILY BACKGROUND AND OTHER INFORMATION 1. What are/were your parents’/stepparents’ name(s) and occupation(s)?

2. What are your siblings’ names? What place are you in the birth order?

3. Who lived with you growing up? What role did they play in your life?

4. What was the quality of your parents’ relationship with each other growing up? What is it like now?

5. Did you parents divorce? If so, who did you live with? What effect did the divorce have on you?

6. Were there any issues in the home growing up such as substance abuse or mental health issues?

7. What is your current relationship with each of your siblings? (For Example: Close, Strained, None, Needs Improvement, etc.)

8. What issues, if any, did you experience during your early adulthood in school, with peers, with substance abuse or mental health?

9. What was the parenting role of your mother and your father growing up?

SECTION 15: PLEASE LIST THE NAMES AND BIRTHDATES OF ALL OTHER ADULTS LIVING IN YOUR HOME 1. 2. 3. 4. 5. 6.

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NAME OF 1ST CHILD:

Cross reference question number from previous page(s) for your answers written on this additional page

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NAME OF 2nd CHILD:

Cross reference question number from previous page(s) for your answers written on this additional page

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NAME OF 3rd CHILD:

Cross reference question number from previous page(s) for your answers written on this additional page

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NAME OF 4th CHILD:

Cross reference question number from previous page(s) for your answers written on this additional page

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