Superior Court of California, County of Inyo Intake Form for Child Custody Mediation Please complete this 2-sided form (and any additional questions included with this form.) Date: ____________________________________ Court Case #: ____________________________ 1 Your name: __________________________________________ Address (if you want your residence address to be private, give a mailing address instead): ___________________________________________________________________________________________ City: _________________________________ State: _______________ Zip: ________________________ Daytime phone#: __________________ Date of Birth: _____________ Male ______Female______ Your lawyer (if you have one): _____________________________________________________________ Address: _________________________________________________________________________________ City: _________________________________ State: _______________ Zip: _______________________ Phone#: _____________________________ Fax#: _____________________________________________ 2 Name of other parent: ____________________________________________________________________ Address: _________________________________________________________________________________ City: _________________________ State: ______ Zip: _________ Phone #: ______________________ 3 List all children (under 18) whom you and the other parent have had together Child’s Name Age Date of Birth Sex (M or F) ___________________________________ ________ ______________ ____________ ___________________________________ ________ ______________ ____________ ___________________________________ ________ ______________ ____________ ___________________________________ ________ ______________ ____________ Check her if you are attaching information about additional children. 4 If you have a disability, the court may be able to make adjustments for you. Do you need any help to come to mediation? _____ Yes _____No If yes, what help do you need? ____________________________________________________________________ 5 Have you ever participated in a custody case about any of the above children? ______Yes _______No If yes, in which state and county? ______________________ Case# if known: _________________________ 6 Are there any safety related issues that impact you or your children? _____ Yes _____No If yes, explain: ____________________________________________________________________________________ 7 Have you or the other parent ever had contact with Child Protective Services? _____Yes _____ No If yes, in which state and county? __________________________________________________________________ 8 9 10 by birth or adoption): Grade in School ____________________ ____________________ ____________________ ____________________ Have you or the other parent ever been involved, as a parent, in a juvenile dependency case about any of the above children? _____ Yes _____No If yes, in which state and county? _________________________Case # if known: _________________________ Are you and the other parent living apart? ________ Yes ________No If yes, how long have you been living apart? __________years __________months _________days Have you ever been abusive to the other parent or been restrained by a restraining order? ____Yes _____No Intake Form for Child Custody Mediation Page 1 of 2 (Family Law) IC FL-102 (1-8-08); IC DV M102 (1-8-08) American LegalNet, Inc. www.FormsWorkflow.com Superior Court of California, County of Inyo Intake Form for Child Custody Mediation Court Case #: ____________________________ 11 Has the other parent been violent or abusive to you? _____Yes _____No If yes, how many times? _______________ If no, please skip to item 19. 12 When was the most recent violence or abuse? (date): _______________________________________________ Please describe the violence or abuse: ______________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Were the children present? _____Yes _____No Was a Law Enforcement report made? _____Yes _____No Agency Name: ____________________________ 13 When was the 2nd most recent violence or abuse? (Date): ________________________________________________________ Please describe the violence or abuse: _________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 14 When was the worst violence or abuse? (Date): _________________________________________________________________ Please describe the violence or abuse: _________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Where the children present? _____Yes _____No 15 Are you worried that the other parent might be violent or abusive to you again? _____Yes _____No 16 Have you ever asked for a restraining order against the other parent? _____Yes _____No If yes, in which state and county? __________________________Case #:_____________________________________________ 17 Do you have a restraining order against the other parent now? _____Yes _____No Court/Case #___________________ If yes, you may bring a support person with you to mediation. Generally, if you have experienced domestic violence or have a restraining order against the other parent, you can meet with the mediator separately. 18 Do you want to meet with the mediator separately? _____Yes _____No If yes, the mediator must meet with you separately if you check on of these spaces: _____I have a restraining order against the other parent. _____I declare, under penalty of perjury under the laws of the State of California, that the other parent has been violent or abusive to me. Sign your name_______________________________ Date: ___________________________ 19 Has the other parent ever been abusive to another family member? _____Yes _____No 20 Has the other parent ever been involved in a criminal domestic violence case? _____Yes _____No If yes, in which state and county? ___________________________Case #:____________________________________________ Intake Form for Child Custody Mediation Page 2 of 2 (Family Law) IC FL-102 (1-8-08); IC DV M102 (1-8-08) American LegalNet, Inc. www.FormsWorkflow.com