Information Sheet-Mediation And Evaluation Service {FCS-4}

Superior Court of California, County of San Mateo Family Court Services 400 County Center, 6th Floor, Redwood City, CA 94063 Tel: (650) 261-5080 ~ Fax: (650) 261-5142 INFORMATION SHEET Please fill out this form completely and bring it with you to your appointment. The information you provide will be used to assist in your upcoming appointment. Failure to bring the completed form with you will delay your appointment time. Please do not attach any additional pages. YOUR CASE #: Personal Information Name: Other names you have used: Birthdate: Birthplace: Age: Home address: City: State: Zip code: Mailing address: City: State: Zip code: Home phone: Cell: Work / message: Email Address: Attorney Information (please complete if you have an attorney) Name: Address: City: State: Zip code: Telephone #: Fax #: Children Involved in This Matter Name: DOB: Age: Lives with: Name: DOB: Age: Lives with: Name: DOB: Age: Lives with: Name: DOB: Age: Lives with: If your children have any special needs, please list them here: FCS-4 (Rev. 03/2017) Page 1 of 4 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com Your Residence How long have you resided at your current address? Number of bedrooms: Do you rent or own? Are you planning to move? Where? Names and relationship to you (including children) of all persons who live at this residence: Employment Information Employer: Address: Date employed: Days & hours of work: Job title: Status of Your Relationship With the Other Parent Married / Domestic Partnership: ( ) Yes ( ) No Date of marriage / domestic partnership: Date began living together: Date of last separation: Date divorce was final / domestic partnership was terminated: Other Marriages / Domestic Partnerships/ Other Children Name: Date: Children from this relationship: Name: Date: Children from this relationship: FCS-4 (Rev. 03/2017) Page 2 of 4 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com If the following is applicable, please read carefully and fill out completely. If it is not applicable, please skip and continue on the next page. Domestic Violence / Restraining Orders When there is a history of domestic violence or a domestic violence restraining order, the protected party may request a separate session and bring a *support person under Family Codes 3181 & 6303. I request a separate session under code section 3181 I wish to bring a support person under code section 6303 Briefly describe any history of domestic violence: Latest incident: Other incidents: Were the police called / any police reports made? o If yes, in what city or county were they involved? o Police report #s (if you have them): Was emergency medical treatment needed? Were weapons involved? Was the Court involved? o If yes, in which county? Were temporary restraining orders issued? Has anyone received counseling or help from a domestic violence agency? o If yes, where? Have the children witnessed any of the domestic violence? o If yes, briefly explain: If you have a copy of a restraining order from another county or a criminal protective order, please provide a copy of the order to your recommending counselor. *Support Person: The support person is there to provide moral and emotional support only. He/she cannot participate in the session or act as an advocate. The support person should not have a dual role (i.e. supervising the visits) or be a person whose presence would be disruptive to the mediation process (i.e. a significant other or a person who has conflict with the other parent). The mediator/ CCRC has the right to exclude a support person if there is a attempts to participate in the session, or the support person attempts to influence the session in any way. The support person must sign and adhere to the support person guidelines in order to support the survivor in the session. FCS-4 (Rev. 03/2017) Page 3 of 4 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com Current Parenting Plan/Schedule Are the children seeing the other parent? o If yes, what is the current parenting plan or schedule in which the child(ren) are with each parent? o If no, what are the current circumstances preventing contact between the other parent and the children? Do you or the other parent have any history or current issues with drug or alcohol abuse? o If yes, please explain briefly: Are there any current charges of child physical or sexual abuse or neglect? o If yes, please explain briefly: Has a dependency petition (W&I 300) been filed with the Juvenile Court? o If yes, please explain briefly: Are there any concerns relating to the safety of the children? o If yes, please explain briefly: Has Child Protective Services (CPS) ever been involved with your family? o If yes, in which county? o Please briefly explain their involvement and the outcome: What custody / visitation challenges, if any, currently exist? Please list some reasonable solutions to the challenges: Under penalty of perjury, I certify all the information provided to Family Court Services is true and correct. I understand falsification or omission of any information may affect the disposition of my case. I understand that Family Court Services staff may consider all other information available regarding my Family Court Services case. Signature: Date: FCS-4 (Rev 03/2017) Page 4 of 4 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com