MAD-FCS-0009 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 1 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#: FCS#: COURT DATE: TYPE OF PETITION: STEP-PARENT ADOPTION ($300) DECLARE MINOR FREE ($300) DUAL STEP-PARENT ADOPTION/DECLARE MINOR FREE ($450) **** NOTE: INVESTIGATION FEE IS DUE FROM THE PETITIONER ON THE DAY OF THE APPOINTMENT *** SECTION 1: PETITIONER222S INFORMATION N AME (Last, First, Middle ) : RELATIONSHIPTO CHILD: MAIDEN NAME : OTHER NAMES KNOWN BY: DATE OF BIRTH : PLACE OF BIRTH : ATTORNEY NAME / TELEPHONE # / FAX # : TEL. # : E - MAIL ADDRESS: HAS THE NON - CUSTODIAL PARENT BEEN SERVED? Yes No STREET ADDRES S : SOCIAL SECURITY # : DRIVER222S LICENSE # / STATE : CITY : STATE : ZIP CODE : HOW LONG AT THIS ADDRESS ? YEARS: MONTHS: SECTION 2 : NATURAL FATHER222S I NFORMATION NAME (Last, First, Middle ) D O YOU CONSENT TO THE ADOPTION/DECLARE THE MINOR FREE PETITION? Yes No OTHER NAMES 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: SECTION 3 : NATURAL MOTHER222S INFORMATION: N AME (Last, First, Middle ) DO YOU CONSENT TO THE ADOPTION/DECLARE THE MINOR FREE PETITION? Yes No OTHER NAMES 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: DECLARE MINOR FREE/ STEP - PARENT ADOPTION INVESTIGATION INTAKE / QUESTIONNAIRE Revised February 2019 American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0009 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 2 SECTION 4: OBJECTING WITNESS INFORMATION NAME (Last, First, Middle) RELATIONSHIP TO CHILD: MAIDEN NAME: 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: SECTION 5 : CONCERNS AND PROPOSALS 1. Reasons for or against the Adoption and/or Declare the Minor Free P etition: a. Petitioners: What are the top three most important reasons why you wish to adopt the child and/or have the child declared free from parental control of a biological parent? b. Natural Parents who do not object to the petition for adoption and/or declare minor free: What are the top three reasons why the petition to adopt and/or declare the minor free should be granted? c. Natural Parents who object to the petition: What are the top three reasons why the petition to adopt and/or declare the minor free should not be granted? d. Is there a current court order? Yes No e. Whether there is a current court order in place or not, please answer the following questions regarding how things are now: a. At this time, who makes decisions about the child/ren222s health, education and welfare? b. At this time, who does the child/ren live with? c. At this time when do the children spend time with each parental figure? f. What has been your involvement regarding the care of the child/ren? 2 American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0009 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 3 SECTION 6 : CONTACT WITH THE COURTS AND OTHER STATE AGENCIES A. CRIMINAL COURT - List all YOUR a rrests in the last 10 years: Date of Arrest : Ch arge(s): Law Enforcement Agency : Outcome : 1. Have YOU ever been court ordered to attend: Batterer222s Intervention Program? Drug Treatment? Anger Management? Counseling? 2. Are you currently on Probation or Parole? Yes No IF YES, please state the name, location and telephone number of your probation/parole officer: 3. Does anyone else currently living in your home have criminal arrests or convictions? Yes No IF YES, please state the name of the person, dates of the arrests, charges and outcomes for all: 4. Have the OTHER parental figures ever been arrested? Yes No IF YES, please state the dates of the arrests, charges and outcomes for all: 5. 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 parental figures or your children? Yes No IF YES, please answer the following questions: Name of Child : Date Investigated : Concerns/Allegations : Outcome of Investigation : SECTION 7: INFORMATION ABOUT YOUR CURRENT BOYFRIEND, GIRLFRIEND, OR SPOUSE: FULL NAME : D ATE OF BIRTH: SOCIAL SECURITY#: OTHER NAMES USED: DRIVER222S LIC.#/STATE: DATE RELATIONSHIP BEGAN: HOME PH#: CELL PH#: OCCUPATION: PRESENT EMPLOYER: EMPLOYER222S PH#: DAYS/HOURS WORK: American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0009 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 4 SECTION 8 : 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 IF YES, what is your occupation, employer222s name, telephone number and employer222s address? 2. How long have you been with your current employer? Years : Months : 3. 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 4. Please list your employment history over the past 5 years: Dates of empl oyment: Name of e mployer : Telephone # : Occupation : Reason for leaving : B. Who takes care of the c hild(ren) while you are unavailable? Please provide their names and telephone #222s: SECTION 9 : 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 # : 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 or petitioner ever been in cou nseling/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: American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0009 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 5 SECTION 11: PLEASE LIST THE NAMES AND BIRTHDATES OF ALL ADULTS LIVING IN THE HOME: 5. Has the other parent or petitioner 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 10 : 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# : 6. Drug u se history: Name of d rug : How o ften : Age of firs