FAMILY COURT SERVICES MEDIATION QUESTIONNAIRE THE PURPOSE OF MEDIATION IS TO HELP SEPARATED OR DIVORCED PARENTS REACH A PARENTING PLAN FOR SHARING THEIR CHILD(REN). DURING MEDIATION, PARENTS COMMUNICATE TO THE TRAINED MEDIATOR, THEIR IDEAS AS TO AN APPROPRIATE CUSTODY AND VISITATION SCHEDULE THEY BELIEVE WILL BE IN THE BEST INTEREST OF THEIR CHILD(REN). THE MEDIATOR WILL NOT IMPOSE AN AGREEMENT ON THE PARENTS (THE MEDIATOR IS NOT A JUDGE), BUT WILL INTERVENE WHEN THE IDEAS OF PARENTS ARE IN CONFLICT IN ORDER TO PROMOTE A SETTLEMENT OR AGREEMENT BETWEEN PARENTS FOR SHARING THEIR CHILD(REN). IN ORDER FOR MEDIATION TO BE SUCCESSFUL, IT IS IMPORTANT FOR PARENTS TO SET ASIDE ANY HOSTILITY OR BITTERNESS FELT TOWARDS EACH OTHER AND TO FOCUS ON WHAT IS IN THE BEST INTEREST OF THEIR CHILD(REN). FURTHERMORE, DURING THE MEDIATION IT IS IMPORTANT FOR BOTH PARENTS TO BRING UP ANY ISSUES OR CONCERNS RELATED TO THE WELFARE OF THEIR CHILD(REN). THIS INFORMATION, HOWEVER SHOULD NOT BE USED AS A TOOL AGAINST THE OTHER PARENT. IT IS NECESSARY FOR PARENTS TO BE FAIR AND COOPERATIVE AS CUSTODY BATTLES TEAR CHILDREN APART. ** IF A PARTY ALLEGING DOMESTIC VIOLENCE IN A WRITTEN DECLARATION UNDER PENALTY OF PERJURY OR A PARTY PROTECTED BY A PROTECTIVE ORDER SO REQUESTS THE MEDIATOR WILL MEET WITH THE PARTIES SEPARATELY AND AT SEPARATE TIMES. PLEASE FILL IN THE BLANKS AND ANSWER QUESTIONS BELOW DATE: ___________________________ NAME: ADDRESS: COURT CASE NO. ____________________________________ DOB: ______________________________ CITY/STATE: _________________________ WORK PHONE: __________________ ____________________________________ ______________________________________ ________________________ HOME/MSG PHONE: OCCUPATION: ______________________________ EMPLOYER: ________________________ WORK SCHEDULE: _______________________________________________________________________ YOU ARE: ( ) MOTHER ( ) FATHER ( ) OTHER: ____________________________________ AGE/BIRTH DATE _________________ _________________ _________________ _________________ -1American LegalNet, Inc. www.FormsWorkFlow.com CHILDREN'S NAME: 1. _______________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ SEX __________ __________ __________ __________ Name of attorney representing you:______________________________________ What brings you to Mediation: ___ ___ ___ ___ ___ ___ Divorce Action Separation/Restraining Order - Marriage between parents Separation/Restraining Order - No marriage between parents Re-modification of custody orders Child custody - No marriage between parents Paternity action 1. Have you had, or do you currently have a problem with alcohol, marijuana, cocaine, methamphetamine, or controlled substances or prescribed medications? _____NO _____YES If yes, explain:__________________________________________________________________ 2. Has the other parent had, or currently does have a problem with alcohol, marijuana, cocaine, methamphetamine, or any other controlled substances or prescribed medications? _____NO _____YES If yes, explain:__________________________________________________________________ 3. Has there been physical violence in your relationship with the other party? _____NO (Go to question #9) _____YES (Go to question #4) 4. How many times has physical violence happened? _________________ 5. When was the last time that it happened? ___ ___ ___ During the last 6 months 6 months to 1 year ago More than 1 year ago 6. Have your child(ren) ever seen violence between you and the other party? _____NO _____YES 7. Was anyone ever injured? _____NO _____YES If yes, who was injured? (Please check all that apply) ___ ___ ___ ___ I was injured The other parent was injured A child was injured Someone else was injured (Who: ________________________________) -2American LegalNet, Inc. www.FormsWorkFlow.com Did anyone receive medical attention? _____NO _____YES If yes, who received medical attention? (Check all that apply) ___ ___ ___ ___ I received medical attention The other party received medical attention A child received medical attention Someone else received medical attention: ____________________________________ 8. Were the police ever involved? _____NO _____YES If yes, was anyone ever arrested? _____NO _____YES If yes, who was arrested? (Check all that apply) ___ ___ ___ I was arrested The other parent was arrested Someone else was arrested: ______________________________________ 9. How concerned are you about future violence with the other parent and the child (ren)? ___ ___ ___ ___ Very concerned Somewhat concerned Not very concerned Not at all concerned What are your concerns? Please describe: ________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 10. Has Child Protective Services (CPS) ever investigated a report about your child(ren)? _____NO _____YES If yes, please explain: __________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 11. Do you have any other issues or concerns that we have not asked about? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ -3American LegalNet, Inc. www.FormsWorkFlow.com