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Petition For Conciliation FAM 012 - California

Petition For Conciliation Form. This is a California form and can be used in Family Law Los Angeles Local County .
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For Court Use Only: Separate Sessions Requested DVPA Filing (Or other DV Matter) Superior Court of California, County of Los Angeles PETITION FOR CONCILIATION--FC ยง 1833 By law, this petition, all files and records in Family Court Services are confidential, *except when a mandated reporting situation (e.g. suspected child abuse) exists. For Court Use Only: Date: ___/___/___ at ___ Appointment Walk-In from Dept. ____ Mediator: This *confidential (see above exception*) Family Court Services (FCS) form must be completed by all parties, and be submitted to FCS prior to, or at the time of the Child Custody/Visitation Mediation. Please print clearly. Party completing the form is the: Matter is: Predissolution Petitioner Respondent Interpreter needed: No Yes _________________________(language) Child Support Guardianship/Probate Postdissolution Paternity (never married) Domestic Violence Case #: ________________________ BG#: ________________________ Next Hearing/Trial Date: _________________ in Dept. _____________ Name: ___________________________________________ Date of Birth: __________ Day/Work Phone #: ___________________ First Middle Initial Last Address: __________________________________________________________________ Home Phone #: ___________________ Number Street (Apt#) City State Zip Occupation: _________________________________________________________________________________________________ Type of Employment Employer Work Hours Days Off Attorney: ___________________________________________________________________________________________________ Name Address (Number, Street, Suite, City, State, Zip) Phone Number OUR CHILDREN FIRST or the PACT (Parent And Children Together) program was completed: No Yes ______________ No Yes (If "yes", approximate date of completion) Other Parent's/Party's Name: ______________________________________ A Separate Interview is Preferred: There currently is, or has been, a Criminal or Children's (Dependency) Court case filed: Mediation is in regards to the following child(ren): Name Date of Birth Age Grade Level of Child If a history of domestic violence and/or a Protective/Restraining Order exists, clients will be interviewed separately (unless otherwise indicated by mediator) No Yes (If "yes", please circle type of court) Parent/Party with whom child resides 1. 2. 3. 4. Name(s) and age(s) of any other child(ren) who reside in your home: - - - - - - - - - - - - - - - - - - - - - PLEASE REVIEW EACH STATEMENT BELOW AND CHECK THE BOXES THAT APPLY - - - - - - - - - - - - - - - - No Yes One or more of the following has occurred in your relationship: Slapping, Punching, Choking, Kicking, Shoving, Grabbing, Forced Sex, Threats of _________________________________(describe), or Other violence __________________________________(describe) -- The violence occurred: -- The violence occurred: No No No No No Yes Yes Yes Yes Yes Less than one year ago Once between the parties More than one year ago More than once between the parties The children have been physically hurt by either you or the other party. The Department of Children and Family Services (DCFS or CPS) is currently, or has been, involved with your children. The police or other law enforcement have been involved with you or the children due to domestic violence. There are protective/restraining orders in effect or pending as a result of domestic violence. Your family has been, or is currently, involved in a Child Custody Evaluation. -Your proposed custody/visitation plan--include concerns (e.g. substance abuse, etc.) that may affect custody/visitation: -There are existing custody/visitation orders: No Yes A controversy exists between the parents/parties and the aid of the court is requested to reach an amicable settlement in the best interest of the child(ren). Dated: _______________, at (City) _________________________, California. FAM 012 (12/12) Signature: _________________________________________________ *FAM012*
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