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Mediation Questionnaire F17A - California
| Mediation Questionnaire Form. This is a California form and can be used in Family El Dorado Local County . |
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THE SUPERIOR COURT COUNTY OF EL DORADO OFFICE OF FAMILY MEDIATION Father's Name: Mother's Name: Case Number Mediation Date Court Date MEDIATION QUESTIONNAIRE **THIS FORM MUST BE COMPLETED BY THE PARENTS AND SUBMITTED TO THE MEDIATION DEPARTMENT PRIOR TO THE MEDIATION DATE FATHER Address Employer Work Address SSN Attorney Address Date of Birth Birth Place Work Phone Home Phone Work Schedule Phone MOTHER Address Employer Work Address SSN Attorney Address Date of Marriage or Cohabitation If dissolution filed, when? Date of Birth Birth Place Work Phone Home Phone Work Schedule Phone Date of Separation By Whom? PLEASE INITIAL HERE IF YOU ARE REQUESTING YOUR ADDRESS AND PHONE NUMBER REMAIN CONFIDENTIAL . **IF YOU ARE BEING PROTECTED BY A RESTRAINING ORDER OR IF YOU ALLEGE DOMESTIC VIOLENCE, YOU HAVE THE RIGHT TO BE SEEN SEPARATELY. If you desire separate mediation, please advise the Family Law Clerk when you set the appointment and advise the mediator at your appointment time. INFORMATION REGARDING THE CHILDREN: Child's full name Date of Birth Parent child resides with 1. 2. 3. 4. Local Form F-17a Rev 5/7/01 ED-F17A 2002 © American LegalNet, Inc. CHILD CUSTODY MEDIATION QUESTIONNAIRE NAME: CASE NO.: DATE: Please answer all of the following questions as completely as possible. This will enable your mediator to assist you and the other parent in working out a custody plan that is in the best interest of your children. Please type or write legibly. 1. What have you told your children about your separation and divorce or this custody dispute? 2. How have you dealt with your children's feelings regarding the breakup of their family or this custody dispute? 3. What changes have you noticed in your children's behavior since the separation, or since this custody action was initiated? 2 Local Form F-17a Rev 5/7/01 2002 © American LegalNet, Inc. 4. Describe each of your children's temperament, personality and special problems as an infant. 5. Describe each of your children's temperament, personality and special problems at the present time. 6. Describe each of your children's major interests, activities and school performance at the present time. 3 Local Form F-17a Rev 5/7/01 2002 © American LegalNet, Inc. 7. Briefly describe some of the positive qualities that attracted you to the other parent. 8. Has there been a history of domestic violence? Yes No Please describe and include evidence in the form of police report, medical reports, etc. 9. Since your separation, with whom have your children resided? Please give names, addresses, approximate dates, and length of time. 4 Local Form F-17a Rev 5/7/01 2002 © American LegalNet, Inc. 10. Since the separation, how much time have your children spent with the other parent? Be specific, state frequency and length of time. 11. Is there an existing child custody order? If so, what is it? 12. Briefly describe the events that led to this custody dispute. 5 Local Form F-17a Rev 5/7/01 2002 © American LegalNet, Inc. LEGAL CUSTODY - Legal Custody defines the decision-making rights and responsibilities relative to your children. A. Sole Legal Custody means that one parent shall have the right and responsibility to make the major decisions relating to the health, education, and welfare of a child. Joint Legal Custody means that both parents shall share the rights and responsibility to make the major decisions relating to the health, education, and welfare of a child. B. Considering the above definitions, which do you favor? Sole Legal Custody or Joint Legal Custody . Explain briefly. PHYSICAL CUSTODY - Physical Custody defines the amount of time children will spend with each parent. A. Sole Physical Custody means that a child shall reside with and under the supervision of one parent, subject to the power of the Court to order visitation. Joint Physical Custody means that each of the parents shall have significant periods of physical. Joint Physical Custody shall be shared by the parents in such a way as to assure a child of frequent and continuing contact with both parents. B. Which do you favor? Sole Physical Custody or Joint Physical Custody . Explain briefly. 6 Local Form F-17a Rev 5/7/01 2002 © American LegalNet, Inc. TIME SHARING - A few examples of possible time sharing plans: · · · · Weekdays with one parent; weekends with the other parent; alternate holidays. Summer with one parent; school year with other parent. Alternating weeks, months, etc. Alternating weekends with additional time during the week. 13. Describe the current timesharing arrangement. 14. Describe the timesharing arrangement you think the other parent wants. 15. Describe the timesharing arrangement you want. 16. Submit two timesharing plans you think would be workable. A. B. 7 Local Form F-17a Rev 5/7/01 2002 © American LegalNet, Inc. 17. Describe your relationship with your children. 18. Describe the activities you share with each of your children. 19. What are the positive and negative results of your children spending time with you? 8 Local Form F-17a Rev 5/7/01 2002 © American LegalNet, Inc. 20. What are the positive and negative results for your children of spending time with the other parent? 21. Approximately how far do you reside from the other parent? 22. Describe your plans for transporting your child/ren between each parent's home. 9 Local Form F-17a Rev 5/7/01 2002 © American LegalNet, Inc. 23. What is your greatest fear regarding the custody and/or welfare of your children? What can be done to eliminate or minimize this fear? 24. Have you or the other parent ever been arrested and/or put in jail or prison? If so, please furnish dates and details. A. Information regarding self (and present spouse). B. Information regarding other parent(s). C. Name and phone number of Probation/Parole Officer for self or other parent(s). 25. Have you or the other parent been hospitalized for emotional or drug related problems? If so, please furnish dates, name of hospital and primary doctor. 10 Local Form F-17a Rev 5/7/01 2002 © American LegalNet, Inc. 26. Have you, the other parent, the children, or anyone residing with you ever received counseling from a psychiatrist, psychologist, or other counselor? If so, furnish the following information: Name (Psychiatrist, Psychologist or Counselor): Address: Phone No.: Name (Family Member or Members): 27. Are you presently under the care of a doctor? If so, please furnish the doctor's name, address, phone number and nature of problem. 28. P
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