Mendocino — MFL-230-EN

Source: https://www.mendocino.courts.ca.gov/system/files/forms-and-filings/mfl-230-en.pdf

Family Court Services/Mediation Intake Form

Parent First Name: Parent Middle Name: Parent Last Name:

Other Parent First Name: Other Parent Middle Name: Other Parent Last Name:

Your MAILING Address – NOT PHYSICAL ADDRESS UNLESS IT IS THE SAME Date:

Your EMAIL:

Your Cell Phone: Your Home Phone: Your Message Phone or Work Phone:

Your Date of Birth: Your Occupation: Your Place of Employment:

Your Attorney’s Name: Other Attorney’s Involved? Please list each attorney and who hired him/her:

List all of your minor children involved in this case:

First Name: Last Name: Birthdate: What School does your Other parent’s Name: child attend? (biological/adoptive parent?):

List all other people who live with you:

First Name: Last Name: Relationship to you:

Please list all open cases you or someone living with you are involved with: The following are a list of examples:

• Dissolution/Divorce • Petition to Declare Paternity • Domestic Violence/Restraining Orders • Juvenile Delinquency • Request for Guardianship • Family Support Order • Juvenile Dependency Case Type: see above examples List which family member is involved/or case #: COURT DATES PENDING:

Do you have open court cases in another county or state? Yes No List case:

INTERPRETATION REQUESTED? Yes Language: No

PREVEIOUS MEDIATION? Yes No

PARENT CHANGING RESIDENCE? Yes No Is anyone planning on moving out of county?

CHILD CUSTODY EVALUTION? Have you ever Yes No participated in a child custody evaluation before? CUSTODY and VISITATION REQUESTS: PHYSICAL CUSTODY (where your child primarily resides): Should be Should be sole to shared one parent LEGAL CUSTODY (making decisions about health, education, welfare): Should be Should be sole to shared one parent DO YOU HAVE ANY DISABILITY THAT WE SHOULD BE AWARE OF?

MFL-230-EN (rev 0922) 1

Family Court Services/DOMESTIC VIOLENCE ASSESSMENT FORM/ SAFETY CONCERNS

This intake page is about domestic violence between you and the other parent. The court has special rules that apply to cases involving domestic violence. Please use this form to alert us of any concerns regarding domestic violence and safety by answering the questions below. Do you have a restraining order or protective order now? NO YES

Have you had a restraining order or protective order in the past? NO YES

Do you feel safe mediating with the other parent? NO YES

Are you and the other parent residing together? NO YES Date of separation, if applicable: Have you experienced any of the following: (please check)

Yelling/Name calling Choking, strangling, smothering

Verbal threats of violence Pushing, shoving

Threats involving guns, knife, other weapons Forced sex

Breaking/throwing things Slapping, hitting, kicking, biting

Hurting pets Other:

How frequently did you experience domestic violence? Were children present?

Child name:

Describe the most recent incident of abuse: Were children present?

Child name:

Describe past incidents of abuse: Were children present?

Child name:

Are you concerned about future domestic violence?

Please check any that apply:

Were police called to incidents of DV? Did you seek medical attention?

Were police reports made? Does the other parent possess weapons?

Were there arrests or convictions? Do you have a plan to protect yourself?

Were reports made to child protective services? Is mental health a concern?

Is drug/alcohol abuse a concern?

MFL-230-EN (rev 0922) 2