FAM 012 (Rev. 07/18) PETITION FOR CONCILIATION FC 247 1833 Mandatory Form Page 1 of 1 Superior Court of California, County of Los Angeles PETITION FOR CONCILIATION227FC 247 1833 By law, this petition, all files and records in Family Court Services are confidential, *except when a mandated reporting situation (e.g. suspected child abuse) exists. Party completing the form is the: Petitioner Respondent Interpreter needed: No Yes (language) Predissolution Postdissolution Paternity (never married) Domestic Violence Child Support Guardianship/Probate Case #: Next Hearing/Trial Date: in Dept. Name: First Middle Initial Last Date of Birth: Day/Work Phone #: Address: Number Street (Apt#) City State Zip Home Phone #: Occupation: Type of Employment Employer Work Hours Days Off Attorney: Name Address (Number, Street, Suite, City, State, Zip) Phone Number Mediation is in regards to the following child(ren): Name Date of Birth Age Grade Level of Child Parent/Party with whom child resides 1. 2. 3. 4. Name(s) and age(s) of any other child(ren) who reside in your home: - - - - - - - - - - - - - - - - - - - - - PLEASE REVIEW EACH STATEMENT BELOW AND CHECK THE BOXES THAT APPLY - - - - - - - - - - - - - - - - - No Yes One or more of the following has occurred in your relationship: Slapping, Punching, Choking, Kicking, Shoving, Grabbing, Forced Sex, Threats of (describe), or Other violence (describe) -- The violence occurred: Less than one year ago More than one year ago -- The violence occurred: Once between the parties More than once between the parties No Yes The children have been physically hurt by either you or the other party. No Yes The Department of Children and Family Services (DCFS or CPS) is currently, or has been, involved with your children. No Yes The police or other law enforcement have been involved with you or the children due to domestic violence. No Yes There are protective/restraining orders in effect or pending as a result of domestic violence. No Yes Your family has been, or is currently, involved in a Child Custody Evaluation. A controversy exists between the parents/parties and the aid of the court is requested to reach an amicable settlement in the best interest of the child(ren). Dated: Signature: This *confidential (see above exception*) Family Court Services (FCS) form must be completed by all parties, and be submitted to FCS prior to, or at the time of the Child Custody/Visitation Mediation. Please print clearly. OUR CHILDREN FIRST program was completed : No Yes (If 223yes224, approximate date of completion) Other Parent222s/Party222s Name: A Separate Interview is Preferred: No Yes If a history of domestic violence and/or a Protective/Restraining Order exists, clients will be interviewed separately (unless otherwise indicated by mediator) There currently is, or has been, a Criminal or Children222s (Dependency) Court case filed: No Yes (If 223yes224, please circle type of court) -Your proposed custody/visitation plan227include concerns (e.g. substance abuse, etc.) that may affect custody/visitation: -There are existing custody/visitation orders: No Yes For Court Use Only: Date: / / at Appointment Walk-In from Dept. Mediator: American LegalNet, Inc. www.FormsWorkFlow.com