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

Superior Court of California, County of San Mateo Family Court Services th 400 County Center, 6 Floor, Redwood City, CA 94063 Tel: (650) 261-5080 ~ Fax: (650) 261-5142 INFORMATION SHEET Bring this completed form with you; failure to complete this form will delay your appointment. Please limit your answers to the space provided and do not attach any additional pages. CASE #: ________________ Personal Information Name: ___________________________________________________________________________ Other names you have used: _________________________________________________________ Birthdate: _________________ Birthplace: ___________________________ Age: ______________ Social Security number: _________________ Driver's License number & State: _________________ Home address: ____________________________________________________________________ City: ________________________________________ State: __________ Zip code: ____________ Mailing address: ___________________________________________________________________ City: ________________________________________ State: __________ Zip code: ____________ Home phone: _________________ Cell: _________________ Work / message: ________________ Attorney Information 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: _______________ Residence How long have you resided at your current address? ______________________________________ Number of bedrooms: ___________ Are you planning to move? _____________________________ Do you rent or own? ______________________ Number of persons at this residence: ___________ 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: ___________________________________ Monthly income before taxes: ______________ 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: _______________________________ FCS-4 (Rev. 05/2013) Page 1 of 3 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com Other marriages / domestic partnerships Name: ______________________________________________ Date: _______________________ Children from this relationship: _______________________________________________________ Name: ______________________________________________ Date: _______________________ Children from this relationship: _______________________________________________________ Health Are you currently receiving any medical treatment? ( ) No ( ) Yes; briefly describe: ______________ ________________________________________________________________________________ Domestic Violence / Restraining Orders (if not applicable, skip & continue with Current Situation) 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 If there is a history of domestic violence against you, either in or outside the children's presence, describe when and where it occurred and who was involved: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ If you have a copy of your declaration or restraining order regarding domestic violence, please provide a copy to your counselor. Otherwise, briefly answer the following: Latest incident: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Worst incident: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Were the police called / any police reports? ____________________________________________ Was emergency medical treatment needed? ___________________________________________ Were weapons involved? __________________________________________________________ Was the Court involved? __________________________________________________________ Were temporary restraining orders issued? ____________________________________________ ______________________________________________________________________________ Has anyone received counseling or help from a domestic violence agency? __________________ ______________________________________________________________________________ Has Child Protective Services been involved? __________________________________________ Have the children witnessed any of the domestic violence? _______________________________ ______________________________________________________________________________ [This space intentionally left blank.] FCS-4 (Rev. 05/2013) Page 2 of 3 www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com [This space intentiona