MAD-FCS-0010 Form Adopted for Mandatory Use Superior Court of Madera County (New 3/06/19) MAD-FCS-0010 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 #: NEXT COURT DATE: FCS #: SECTION 1: YOUR NAME : YOUR N AME (Last, First, Middle ) : EMAIL ADDRESS ( PRINT CLEARLY ) : DATE OF BIRTH : ATTORNEY NAME / TELEPHONE # / FAX # : TEL EPHONE # : HOME ADDRESS : CITY : STATE : ZIP CODE : MAILING ADDRESS IF DIFFERENT THAN HOME ADDRESS: (IMPORTANT YOU INCLUDE TO RECEIVE CORRESPONDENCE) ` What is your relationship to the child ? *NOTE: REPORTS WILL BE E - MAILED TO YOU AT THE E - MAIL ADDRESS YOU PROVIDE ABOVE * SECTION 2 : OTHER PAR TY /NATURAL PARENT(S) INFORMATION (FILL OUT AS BEST YOU CAN) : N AME (Last, First) : ADDRESS : CITY : STATE : ZIP CODE : DATE OF BIRTH : TEL EPHONE # : ADDRESS WHERE THE OTHER PARTY WAS SERVED : N AME (Last, First): ADDRESS: CITY: STATE: ZIP CODE: DATE OF BIRTH: TEL EPHONE # : ADDRESS WHERE THE OTHER PARTY WAS SERVED: SECTION 3 : 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 a verbal agreement only between you and the other party, please answer the following: a. According to the plan, who is supposed to make major decisions about the child(ren)222s health, education and welfare? b. According to the plan, who does the child(ren) live with? GRANDPARENT/STEPPARENT MEDIATION INTAK E / QUESTIONNAIRE February 2019 American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0010 Form Adopted for Mandatory Use Superior Court of Madera County (New 3/06/19) MAD-FCS-0010 Page 2 c. According to the current plan , w hen is the c hild ( ren ) supposed to visit the Grandparent/Stepparent ? 4. Do you want the current visitation plan to change? Yes No IF YES, please answer the following: a. I want to change the schedule of when the child(ren) spends time with the Grandparent(s)/Stepparent to: 5. If you want the current visitation to change, how would your proposed changes benefit the child(ren)? SECTION 4 : CHILD/REN222S INFORMATION (FILL OUT ALL INFORMATION AS BEST YOU CAN) NAME: (First) (Last) DOB GRADES (A222s, B222s?) / ATTENDANCE : THIS CHILD HAD COUNSELING? Yes No Yes No Yes No Yes No SECTION 5 : ABOUT THE NATURAL PARENT ( S )/GRANDPARENT(S)/STEPPARENT ( DO NOT LEAVE BLANK ) : 1. What are the ir strengths ? 2. What are their weaknesses? 3. Have the parents or other parties ever been in counseling or had substance abuse issues? Yes No IF YES, when and for what issue(s)? 4. Have the parents/grandparents/stepparent ever been arrested? Yes No IF YES, WHO, when, and for what charge(s)? SECTION 6 : YOUR INVOLVEMENT IN COUNSELING, THE COURTS AND CPS 1. Have you ever been in counseling or had substance abuse issues? Yes No IF YES, for what issue (s) ? 2. Have you ever been arrested? Yes No IF YES, when and for what charge(s)? 3. Has Child Protective Services (CPS) ever been involved with your family for allegations of child abuse or neglect? Yes No IF YES, when and what was the outcome? American LegalNet, Inc. www.FormsWorkFlow.com