Marin — FL016

Source: https://www.marin.courts.ca.gov/system/files/forms-and-filing/fl016-en-family-court-services-intake-fillable-5-25.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF MARIN P.O. Box 4988 San Rafael, CA 94913-4988 CONFIDENTIAL DATE: CASE NO.

YOUR INFORMATION OTHER PARENT’S INFORMATION

Name Name Mailing Addr. Mailing Addr. City/Zip City/Zip Cell Phone Cell Phone Email Email Interpreter needed. Language Interpreter needed. Language

YOUR ATTORNEY OTHER PARENT’S ATTORNEY Self Represented Litigant Self Represented Litigant Name Name Mailing Addr. Mailing Addr. Email Email

CHILD(REN) AT ISSUE Name: D.O.B.: Living With: Name: D.O.B.: Living With: Name: D.O.B.: Living With: Name: D.O.B.: Living With:

1. Are there orders from another county or from juvenile court concerning your children? YES NO
2. Is there a currently open Child and Family Services Case (CFS or CPS)? YES NO
3. Are you currently concerned about your safety? ** YES NO
4. Are there police reports for abuse/violence for you, your children, or the other parent? ** YES NO
5. Have you or the other party ever had a Protective Order or Restraining Order? ** YES NO If the answer is yes to #5, what date was it issued?_________________ Has it expired? YES NO
6. Is there any past/current Criminal Case for you or the other party? YES NO
7. Have you reviewed the FCS Orientation materials? YES NO
8. One or more of the following has occurred in your relationship:
   • Physical Violence and/or Sexual Assault YES NO Describe

   -Threats YES NO Describe

   • Other DV (Stalking, Disturbing the Peace, ect.) _______________________________________ YES NO Describe

PARTNER ABUSE PROCEDURES NOTICE (California Rules of Court 5.215): If a party to this action has made a written allegation of domestic violence under penalty of perjury or is a party protected by a Restraining Order then that party may request separate sessions and/or have a support person present in session. If you are the protected party, you may waive separate sessions, as applicable (Family Code Section 3181). **IF YOU ARE A VICTIM OF PARTNER ABUSE AS DEFINED ABOVE AND REQUEST SEPARATE SESSIONS, PLEASE CHECK HERE *** Under penalty of perjury, I swear I have completed the above information truthfully and to the best of my knowledge. I agree to appear at all sessions and to cooperate in the mediation or child custody recommending counseling process.

SIGN

SIGN ______________________________________________ DATE

FL016 FAMILY COURT SERVICES INTAKE SHEET - ENGLISH Rev. 05/08/2025