Family Court Services CCRC Intake Form PCS - 25 R07 - 19 CCRC Info Sheet and Intake Form Page 1 of P lease read this ENTIRE packet very carefully. This document will provide you with important inform ation about your u pcoming CCRC appointment. You MUST complete this CCRC Intake Form PRIOR to your CCRC appointment . The counselor will use this form to familiarize themselves with your family and to be better prepared to meet your needs during the CCRC session. The FCS CCRC Intake Form will NOT be shared with the Judicial Officer or the other parties on the case. Purpose of CCRC Session : The counselor may use the CCRC session to provide the parties with additional mediation services. During the mediation portion of the CCRC session, the counselor can help parties formulate a parenting p lan regarding the following issues: How the children will spend time with each party (regular time and holidays) How the parties will make legal decisions about the children How the children will be transported and exchanged for the visits Participation in programs or services that may be beneficial for the family Safety Considerations ***Although parents are expected to actively participate in the mediation process, parents are in NO WAY obligated to agree to a parenting plan*** Another purpose of the CCRC session is to provide the court with a report and recommendation from the counselor. o To provide the counselor with the information they need to develop and support their report and recommendation to the court, the CCRC session may include but not b e limited to, interviews with the parents, child(ren), other parties who may be legally joined to the case, and other individuals or organizations who may have information about the current family circumstances. The counselo r will write and submit a CCRC r eport that may include, but not be limited to, a brief description of collateral cont acts with law enforcement or Child Protective Services, interviews with the child(ren), etc. SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO FAMILY COURT SERVICES Fresno, CA 93721 (559)457 - 2100 (option #4) FresnoFCS@fresno.courts.ca.gov Family Court Services Child Custody Recommending Counseling (CCRC) Intake Form American LegalNet, Inc. www.FormsWorkFlow.com Family Court Services CCRC Intake Form PCS - 25 R07 - 19 CCRC Info Sheet and Intake Form Page 2 of Interviewing Children: The counselor has the discr etion to interview all children ages 5 and older associated with the case. To ensure that the children are available to participate in a private interview with the counselor, please make sure to bring all children ages 5 and older to the CCRC appointment at FCS . Because the couns elor will typically be meeting with the parents together, this means that neither parent will be available to wait with the child ( ren ) in the FCS lobby . You will need to bring a NEUTRAL adult to supervise the child(ren) in the FCS lobby while you are meeting with the counselor or you will need to bring Photo ID to check the child(ren) in the Sisk Courthouse Childcare Center (located on the 1 st floor, next door to the FCS office). If you are using the Childcare Center, please c heck your child ( ren ) into the childcare center BEFORE you r scheduled appointment time. If ordered by the Court, the counselor will conduct a private interview with the child(ren), the parties will NOT be included when the counselor interviews the child(ren). Confidentiality : The CCRC session is NOT confidential and the counselor will provide a report and recommendation to the Court . The counselor may also share information with other professional agencies in the following circumstances: If the counselor determines there is reasonable suspicion of danger to one of the parties or others, the counselor is required to report suspected child abuse, elder abuse, and/or if someone is a danger to themselves or others to the appropriate agency. Documents: The counselor has access to documents filed with the Court. The counselor has discretion to discuss documents provided by the parents during the CCRC session, for the sole purpose of mendation . After submitting the report and recommendation to the Court, t he counselor will NOT retain any documents presented by the parties during the CCRC session . If you want your documents to be considered by the Judicial Officer you must file the do cuments with the Court. Interpreters: If you do not speak English, you must bring your own interpreter to your CCRC appointment . Failure to bring your own interpreter may result in cancellation of your CCRC appointment. Si usted no habla Ingl351s, usted debe traer su propio int351rprete. La falta de traer su propio int351rprete puede resultar en la cancelaci363n de su Mediaci363n de custodia de los hijos. American LegalNet, Inc. www.FormsWorkFlow.com Family Court Services CCRC Intake Form PCS - 25 R07 - 19 CCRC Info Sheet and Intake Form Page of Separate Sessions : Pursuant to Family Code 2473181 , where there has been a history of domestic violence between the parties or where a protective order as defined in 2476218 is in effect, at the request of the party alleging domestic violence in a written declaration under penalty of perjury or protected by t he order, the counselor appointed pursuant to this chapter shall meet with the parties separately and at separate times. If you feel that separate sessions are appropriate due to a history of domestic violence, please contact Family Court Services IMMEDI For additional information: www.fresno.courts.ca.gov/family/familycourtservices.php email: FresnoFCS@fresno.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO PERSONAL INFORMATION Name: Other Names Used: (First) (Middle) (Last) (Nickname, Aliases, Maiden Name) Address: City: (Number and Street Name) (Apartment No.) State: Zip: County: Email: Phone Number(s): ( ) ( ) Date of Birth: (Home) (Work / Cell) Date of Birth: (First) (Middle) (Last) EMPLOYMENT Employer Work Schedule : MON TUES WED THURS FRI SAT SUN Work Hours: ATTORNEY N ame : Phone Number : Email: MINOR CHILDREN IN THIS CASE OTHER MINOR CHILDREN N ame DOB School Name DOB School OTHER ADULTS IN YOUR HOME N ame DOB Relationship Name DOB Relationship DOMESTIC VIOLENCE 1. Is there currently a Restraining Order in effect protecting you or the other parent? YES NO Expiration date: 2. Are you, under penalty of perjury , alleging that there is a history of domestic violence between you and the other parent? YES NO 3. If you answered YES to question #2: W ere the child /ren present during the violence? YES NO Was medical attention required? YES NO YES NO YES NO 4. Were any weapons involved? Was Law Enforcement involved? YES NO via ema il at FresnoFCS@fresno.courts.ca.gov to receive a packet regarding your request for separate mediation sessions. FAMILY COURT SERVICES CCRC INTAKE FORM Case Number: PCS-25 R07-19 CCRC Info Sheet and Intake Form Page of American LegalNet, Inc. www.FormsWorkFlow.com QUESTIONNAIRE 1 . Do you currently have a Court order for custody and visitation: YES NO Describe how much time each parent has with the child/ren since your separation? 2 . Please provide a detailed visitation schedule, including specific days and times for exchanges: Visitation schedule : Sole Legal Sole Physical Joint Legal Joint Physical Holiday Schedule: Easter: Thanksgiving: Christmas: 3 . Approximately, how many miles do you reside from the other parent ? 4. Major areas of concern that would justify limited contact between the child/ren and the other parent: Substance abuse Exposure to criminal behavior/Arrest History Neglect of medical care History of child abuse / CPS/ Police involvement Use of inappropriate discipline Unavailability of other parent to care for the child/ren 5. Briefly s ummarize the concerns you have regarding the custody and/or welfare of the child/ren: 6. Do the child / ren have any special needs that could impact custody/visitation? 7. Do you, the other parent and / or your child/ren have mental health needs: YES NO Name Nature of Problem Name of Clinician Psychiatric Hospitalization Phone # YES NO YES NO 8. Ha