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SUPERIOR COURT OF CALIFORNIA
COUNTY OF FRESNO
PERSONAL INFORMATION
Name:
Other Names Used:
(First) (Middle) (Last) (Nickname, Aliases, Maiden Name)
City:
(Number and Street Name) (Apartment No.)
Zip:
County:
Email:
Address:
State:
Phone
Number(s):
Date of Birth:
(Home) (Work / Cell)
OTHER PARENT / PARTY’S PERSONAL INFORMATION
Other Parent’s / Party’s Name:
(First) (Middle) (Last)
EMPLOYMENT
Employer (If Unemployed, Please Write “Unemployed”):
Work Schedule:
MON
TUES
WED
THURS
FRI
SAT
SUN
Work Hours:
ATTORNEY
Name: Phone Number:
Name DOB School Name DOB School
OTHER ADULTS IN YOUR HOME
Name DOB Relationship Name DOB Relationship
DOMESTIC VIOLENCE
1.
Is there currently a Restraining Order in effect protecting you or the other parent?
YES
NO
Expiration date:
2.
Are you, under penalty of perjury, alleging that there is a history of domestic violence between you and the other parent?
YES NO
3. If you answered YES to question #2:
YES NO
YES NO
4.
Were the child/ren present during the violence? NO Was medical attention required? YES
Were any weapons involved? NO Was Law Enforcement involved? YES
YES NO
If yes to #4, would you like for the FCS staff to provide you with information about creating a Safety Plan:
YES NO
If you answered ‘YES’ to questions #2 and #4, please immediately contact Family Court services by calling (559) 457-2100 and selecting
option #4 to receive a packet regarding your request for separate mediation sessions.
FAMILY COURT SERVICES TIER 1 INTAKE FORM
Case Number:
Are you requesting a separate mediation session due to a history of domestic violence between you and the other parent?
PFC-15 R06-20
MANDATORY
FAMILY COURT SERVICES TIER 1 INTAKE FORM
Email:
MINOR CHILDREN IN THIS CASE
QUESTIONNAIRE
1.
Do you currently have a Court order for custody and visitation: YES NO
Describe how much time each parent has with the child/ren since your separation?
2.
Please provide 2 detailed visitation schedule options, including specific days and times for exchanges:
Visitation schedule 1:
Sole Legal
Sole Physical
Joint Legal
Joint Physical
Holiday Schedule:
Easter:
Thanksgiving:
Christmas:
Visitation schedule 2:
Sole Legal
Sole Physical
Joint Legal
Joint Physical
Holiday Schedule:
Easter:
Thanksgiving:
Christmas:
3.
Approximately, how many miles do you reside from the other parent?
4.
Major areas of concern that would justify limited contact between the child/ren and the other parent:
Substance abuse
Exposure to criminal behavior/Arrest History
Child/ren’s resistance to visitation
Child/ren’s poor academic performance
Neglect of medical care
History of child abuse / CPS/ Police involvement
Use of inappropriate discipline
Unavailability of other parent to care for the child/ren
Briefly summarize the concerns you have regarding the custody and/or welfare of the child/ren:
Do th
e
child/ren
have any special needs
that
co
uld
i
mpact
custody/visitation?
SIGNATURE
I declare that the foregoing information, as provided in this entire form, is true and correct.
(Date)
(Signature)
/S/
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FAMILY COURT SERVICES TIER 1 INTAKE FORM
PFC-15 R06-20
MANDATORY