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Supplemental Questionnaire F-17b - California

Supplemental Questionnaire Form. This is a California form and can be used in Family El Dorado Local County .
 Fillable pdf Last Modified 5/29/2014
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THE SUPERIOR COURT OF CALIFORNIA COUNTY OF EL DORADO OFFICE OF CHILD CUSTODY RECOMMENDING COUNSELORS Father's Name: Mother's Name: Case Number: Child Custody Counseling Date: Court Date: SUPPLEMENTAL QUESTIONNAIRE ATTENTION: DO NOT ATTACH ANY DOCUMENTS TO THIS FORM; YOU MUST FILE ALL DOCUMENTS YOU WANT CONSIDERED TO YOUR COURT FILE This form is to be filled out and returned if you have been in mediation within the past year or less. If you have previously not attended mediation, the more comprehensive form needs to be filled out. Please return the completed form no less than five days prior to your scheduled mediation appointment. Father's Address: __________________________________________ Number, Street, City, State and Zip Code Father's Employer: _________________________________________ Father's Attorney: __________________________________________ Mother's Address: __________________________________________ Number, Street, City, State and Zip Code Mother's Employer: _________________________________________ Mother's Attorney: __________________________________________ Home Phone: ______________ Work Phone: _______________ Home Phone: ______________ Work Phone: _______________ Date(s) of last mediation: ____________________ Date of last Court hearing: _________________ Is there current domestic violence in your relationship with the other parent? Check one: Yes ___ No ___ Please describe: _______________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Is there a current Restraining Order? Check one: Yes ___ No ___ Name of individual restrained: _____________________________ 1 If so, date of expiration: __________ Local Form F-17b Rev 05-09-2014 American LegalNet, Inc. INFORMATION REGARDING THE CHILDREN: Child's full name Age Date of Birth 1. Briefly describe the events that led to this current custody dispute (change of circumstances, concerns regarding the best interests of the children). 2. Do you have any of the following concerns regarding your children? (check all that apply) ____ Child unhappy with current plan ____ Physical/emotional/sexual abuse of child ____ School adjustment/difficulties ____ Change of child's residence ____ Emotional/behavioral problems 3. Do you have any of the following concerns regarding the other parent? (check all that apply) ____ Substance Abuse ____ Abuse of child ____ Domestic Violence ____ Emotional Instability ____ Legal issues/incarceration 4. Is there an existing child custody/visitation order? 5. Are you requesting a change in either physical or legal custody? Please check the corresponding box. LEGAL CUSTODY: ____ Sole Legal Custody ____ Joint Legal Custody PHYSICAL CUSTODY ____ Sole Physical Custody ____ Joint Physical Custody 2 Local Form F-17b Rev 05-09-2014 American LegalNet, Inc. 6. Are you requesting a change in the current time-sharing plan? Submit two plans you think would be workable. A. B. 7. Have you or any member of the family received any of the following services in the past six months? ___ Counseling: _________________________________________________________________ Name/Phone # of therapist ___ Child counseling: _____________________________________________________________ Name/Phone # of the therapist ___ Substance Abuse Treatment: ___________________________________________________ Name/Phone # of provider ___ Anger Management: __________________________________________________________ Name of program/Contact Phone # ___ Probation/Parole: ____________________________________________________________ Name of Officer /Contact Phone # ___ Co-Parenting: _______________________________________________________________ Name of program/Contact Phone # ___ Physician/Psychiatrist: ________________________________________________________ Name of doctor/Contact Phone # 8. Please provide the following information for all of your minor children: Child's Name School Name Teacher's Name School Address Phone Number 3 Local Form F-17b Rev 05-09-2014 American LegalNet, Inc. 9. What could you do to encourage a cooperative and acceptable resolution of the custody dispute? 10. Is there anything else we should know about this case? IMPORTANT: Should you move or change your telephone number prior to your child custody recommending counseling appointment, please notify this office immediately. Dated: Signature: _________________________________ __________________________________________________________ 4 Local Form F-17b Rev 05-09-2014 American LegalNet, Inc.
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