Form Adopted for Mandatory Use Superior Court of Madera County Rev. 6/5/18 MAD-0032 STATE OF CALIFORNIA MADERA SUPERIOR COURT Family Court Services 200 South G Street Madera, CA, 93637 PH #: 559-416-5560 FAX #: 559-673-8216 CASE # NEXT COURT DATE: NOTE: INVESTIGATION FEE OF $600 / PARENT IS DUE ON THE DAY OF YOUR APPOINTMENT SECTION 1: YOUR INFORMATION NAME (Last, First, Middle Initial) MAIDEN NAME OTHER NAMES YOU ARE KNOWN BY DATE OF BIRTH PLACE OF BIRTH ATTORNEY NAME / TELEPHONE # / FAX # HOME TEL. # CELL TEL. # E - MAIL ADDRESS: STREET ADDRESS SOCIAL SECURITY # DRIVER222S LICENSE # / STATE CITY STATE ZIP CODE HOW LONG AT THIS ADDRESS YEARS: MONTHS MAILING ADDRESS IF DIFFERENT THAN HOME ADDRESS: (IMPORTANT YOU INCLUDE TO RECEIVE CORRESPONDENCE)` SECTION 2 : CONCERNS AND PROPOSALS 1. What are the top three most important concerns you would like to discuss with Family Court Services? 2. Is there a current court order? Yes No 3. Whether there is a court order or not, please answer the following questions regarding how things are now: a. At this time, who makes decisions about the child(ren)222s health, education and welfare? b. At this time, who do the children live with? c. At this time when do the children spend time with each parent? 4. Do you want to change how things are now? Yes No If yes, please answer the following: a. I want to change who makes decisions about the children222s health, education and welfare) to: b. I want to change who the child/ren live with to: c. I want to change the schedule of when the children spend time with each parent to: CHILD CUSTODY INVESTIGATION INTAKE/QUESTIONNAIRE January 2016 American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Mandatory Use Superior Court of Madera County Rev. 6/5/18 MAD-0032 5. If you want the current parenting plan to change , how would your proposed changes benefit the children ? SECTION 3 : CONTACT WITH THE COURTS AND OTHER STATE AGENCIES A. CRIMINAL COURT 1. List all YOUR arrests in the last 10 years: Date of Arrest Charge(s) Law Enforcement Agency Outcome 2. Have you ever been court ordered to attend: Batterer222s Intervention Program? Drug Treatment? Anger Management? Counseling? 3. Are you currently on Probation or Parole? Yes No IF YES, please state the name, location and telephone number of your probation/parole officer: 4. Does anyone else currently living in your home have criminal arrests or convictions? Yes No IF YES, please state the dates of the arrests, charges and outcomes for all: 5. Has the OTHER parent ever been arrested? Yes No IF YES, please state the dates of the arrests, charges and outcomes for all: 6. Does anyone else currently living in the other parent222s home have criminal arrests or convictions? Yes No IF YES, please state the dates of the arrests, charges and dispositions for all: B. CHIL D PROTECTIVE SERVICES 1. Has Child Protective Services ever received a referral on you, the other parent or your children? Yes No IF YES, please answer the following questions: Date Investigated Concerns/Allegations Outcome of Investigation American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Mandatory Use Superior Court of Madera County Rev. 6/5/18 MAD-0032 SECTION 4 : INFORMATION ABOUT YOUR CURRENT BOYFRIEND, GIRLFRIEND, OR SPOUSE: Full n ame: Date of birth: Social Security # : Other names used: Driver222s l icense #/ State: Date relationship b egan: Home phone number: Cell phone number: Occupation: Present e mployer: Employer222s p hone #: Days/Hours worked: SECTION 5 : INFORMATION ABOUT ALL PRIOR BOYFRIENDS/GIRLFRIENDS OR SPOUSES Name : Date r elationship Date DOB : Social s ecurity #: Last known a ddress : Began: ended: SECTION 6 : EDUCATION AND EMPLOYMENT A. Education Level : Please list the highest grade or level of schooling you completed: GED High school graduate College courses taken College graduate Post graduate work 1. Are you currently employed? Yes No 2. IF YES, what is your occupation, employer222s name, telephone number and employer222s address? 3. How long hav e you been with your current employer? Years Months 4. Current workdays and hours (please list what time you start work and what time you end work each day) : SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 5. Please list your employment history over the past 5 years: D ates of employment Name of e mploy er Telephone # Occupation Reason for leaving 6. Who takes care of the c hild(ren) while you are unavailable? Please provide their names and telephone #222s: SECTION 7 : MENTAL HEALTH HISTORY 1. Have you ever been in counseling or therapy? Yes No IF YES, please list in chronological order (by year) the therapists, counselors, clergy and/or marital counselors who you gone to: Date : Doctor/Therapist n ame : Complete mailing a ddress : Telephone # : American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Mandatory Use Superior Court of Madera County Rev. 6/5/18 MAD-0032 2. Have you ever been hospitalized for psychiatric treatment? Yes No IF YES, please list hospitals or clinics attended and the dates of treatment: Date Hospital n ame Complete mailing a ddress Telephone # : 3. Have you ever taken psychiatric medication? Yes No (for example, for depression, anxiety, etc.) IF YES, please list the names of all medications and the name, telephone number and the complete mailing address of the physician who prescribed the medication. 4. Has the other parent ever been in counseling/therapy or hospitalized for psychiatric treatment? Yes No IF YES, please list the therapist, agency or hospital that provided the services and the dates of treatment: 5. Has the other parent ever taken psychiatric medication? Yes No IF YES, please list the names of all medications and the name, telephone number and the complete mailing address of the physician who prescribed the medication: SECTION 8 : ALCOHOL AND SUBSTANCE ABUSE HISTORY 1. What kind(s) of alcohol do you drink? 2. How often do you drink? 3. Has your drinking ever been an issue between you and your family or friends? Yes No 4. Are you currently in or have you ever received treatment for alcohol abuse? Yes No If yes, please check all applicable treatment: Counseling/Therapy Detox Rehab Inpatient Rehab Outpatient AA/NA 5. If a box was checked, please list, in chronological order, the therapist/agency/hospital utilized: Date : Therapist/Hospital : Complete mailing a ddress : Telephone number : 6. Drug u se history: Name of d rug : How o ften : Age of first u se : Date of last u se : 7. Prescription drug u se history: Name of d rug / # milligrams: How o ften taken: Prescribing d octor: Doctor222s phone n umber: Do you have a medical marijuana card? Yes No Expiration Date: Have drugs or alcohol ever caused you to lose a job? Yes No Has your drug use ever been an issue between you and your family and friends? Yes No Have you ever been court ordered for drug testing? Yes No IF YES, When:: Were the results of the drug tests positive? For what drugs? American LegalNet, Inc. www.FormsWorkFlow.com Form Adopted for Mandatory Use Superior Court of Madera County Rev. 6/5/18 MAD-0032 SECTION 9 : CHILD(REN)222S INFORMATION: CHILD # 1: / WHO THEY LIVE WITH: Child222s DOB: Age: Grade Level School/Daycare Name: School/Daycare Address: School/Daycare Telephone # Teacher/Daycare Provider Name: Principal Name: Pediatrician Name: Pediatrician222s Address: Pediatrician222s Telephone #: - Does this child presently have physical or emotional problems? Yes No If yes, what is the issue? - Is this child presently in individual counseling or children of divorce group? Yes No Professional222s/Agency Name: Therapist222s Address/phone # CHILD # 2: / WHO THEY LIVE WITH: Child222s DOB: Age: Grade Level School/Daycare Name: School/Daycare Address: School/Daycare Telephone # Teacher/Daycare Provider Name: Principal Name: Pediatrician Name: Pediatrician222s Address: Pediatrician222s Telephone #: - Does this child presently have physical or emotional problems? Yes No If yes, what is the issue? - Is this child presently in individual counseling or children of divorce group? Yes No Professional222s/Agency Name: Therapist222s Address/phone # CHILD # 3: / WHO THE