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Information Sheet-Mediation And Evaluation Service FCS-4 - California
| Information Sheet-Mediation And Evaluation Service Form. This is a California form and can be used in Family San Mateo Local County . |
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SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO FAMILY COURT SERVICES 400 COUNTY CENTER, 6TH FLOOR REDWOOD CITY, CA 94063 TEL: (650) 363 4561 FAX: (650) 363 4966 INFORMATION SHEET - MEDIATION & EVALUATION SERVICE CONFIDENTIAL Failure to complete this form will delay your appointment, bring completed form with you. Please limit your answers to the space provided. COURT #________________ Your name: ______________________________________________________________________ Other names you have used: _________________________________________________________ Birthdate: _________________ Birthplace____________________________ Age:______________ Social security number: __________________ Driver's license number: ____________________ Home address: ____________________________________________________________________ City________________________________________State_____________Zip code_____________ Mailing address: ___________________________________________________________________ City________________________________________State______________Zip code_____________ Telephone # :home____________________________ Work/message_________________________ Attorney's name: __________________________________________________________________ Address: _________________________________________________________________________ City________________________________________State______________Zip code_____________ Telephone number____________________________Fax number____________________________ Children involved in this matter: Name: _____________________DOB: ____________ Name: _____________________DOB: ____________ Name: _____________________DOB: ____________ Name: _____________________DOB: ____________ Age: _________Lives with_______________ Age: _________Lives with_______________ Age: _________Lives with_______________ Age: _________Lives with_______________ Residence: How long in your present address?__________ Rent or Own Number of persons in home: ________ Number of bedrooms: ___________ Are you planning to move? ( )No ( ) Yes: __________________ All others residing in your current residence: Their relationship to you (including children.) _________________________________________________________________________________ _________________________________________________________________________________ Your employment information: Employer: __________________________________Address: _______________________________ Date employed: ________________ days/hours of work: ___________________________________ Job title: ___________________________________Monthly income before taxes: _______________ Status of your relationship with the other parent: Married: ( )Yes ( ) No If divorced, date divorce was final: __________________________________ Date began living together: _____________________Date of last separation: ___________________ Other marriages: Name(s): ____________________________________________date(s): _______________________ Children from those marriages: ________________________________________________________ Health: Are you presently receiving any medical treatment? ( ) No ( ) Yes: briefly describe: ______________ _________________________________________________________________________________ Domestic Violence: If not applicable, skip this section & continue with * CURRENT SITUATION. When there is a history of domestic violence or a domestic violence restraining order, the protected person may request separate mediation and bring a support person under Family Codes 3181 & 6303 _____I request separate mediation under code section 3181 _____I wish to bring a support person under code section 6303 FCS-4 [Rev.05/05] Page 1 of 2 www.sanmateocourt.org American LegalNet, Inc. www.USCourtForms.com History and Background of Domestic Violence: If there is a history of violence against you or the children please describe when, where and who was involved? _________________________________________________________________________ _________________________________________________________________________________ If you have a copy of your declaration or restraining order regarding Domestic Violence, please provide a copy to the mediator. Otherwise, please briefly answer the following: Latest incident:________________________________________________________________ ______________________________________________________________________________ Worst incident:________________________________________________________________ ______________________________________________________________________________ Police called? emergency medical treatment? weapons involved? _______________________ ______________________________________________________________________________ ______________________________________________________________________________ Court involvement? Temporary restraining orders issued? _____________________________ ______________________________________________________________________________ Any counseling or help from domestic violence agency? _______________________________ Has Child Protective Services been involved?____ ___________________________________ Have the children witnessed the Domestic Violence occurring?__________________________ ______________________________________________________________________________ * Current situation: Please limit your answers to the space provided. Are the children seeing the other parent? ___________________________________________ Do you or the other parent have any history or current issues with drug/alcohol abuse?_______ ____________________________________________________________________________ Are there any current charges of child physical abuse, sexual abuse or neglect? ____________ ____________________________________________________________________________ Has a dependency petition (W&I 300) been filed?_____________________________________ Are there any problems relating to the safety of the children? ___________________________ What hours of the day, days of the week, or week of the month do you spend time with or see your children? ________________________________________________________________ ___________________________________________________________________________ What custody/visitation problems currently exist? __________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ____________________________
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