MAD-FCS-0007 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 CASE: INITIAL GUARDIANSHIP GUARDIANSHIP TERMINATION SUCCESSOR GUARDIANSHIP NOTE: INVESTIGATION FEE OF $600 IS DUE FROM THE PETITIONER ON THE DAY OF THE APPOINTMENT SECTION 1: PETITIONER222S INFORMATION N AME (Last, First, Middle ) : RELATIONSHIP TO CHILD: MAIDEN NAME : OTHER NAMES KNOWN BY: DATE OF BIRTH: PLACE OF BIRTH : ATTORNEY NAME / TELEPHONE # / FAX # : HOME TEL. # : CELL TEL. # : E - MAIL ADDRESS: 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) DO YOU OBJECT TO THE GUARDIANSHIP? 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 OBJECT TO THE GUARDIANSHIP? 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 4: OBJECTING WITNESS INFORMATION NAME (Last, First, Middle) RELATIONSHIP TO CHILD: MAIDEN NAME OR OTHER NAMES KNOWN BY: DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX # : HOME TEL. # : CELL TEL. # : E - MAIL ADDRESS: GUARDIANSHIP INVESTIGATION INTAKE/QUESTIONNAIRE Revised February 2019 American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0007 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 2 STREET ADDRESS : CITY/STATE/ZIP CODE: HOW LONG AT THIS ADDRESS ? YEARS: MONTHS: S.S.#: DRIVER222S LICENSE # / STATE: SECTION 5 : CONCERNS AND PROPOSALS 1. Reasons for or against the guardianship petition: a. Petitioners: What are the top three most important reasons why you should be the Guardian of the child/ren? b. Natural Parents who do not object to the petition for guardianship: What are the top three reasons why each petitioner should be granted Guardianship of the child/ren? c. Natural Parents who object to the petition: What are the top three reasons why each petitioner should not be a Guardian of the child/ren? d. Was Temporary Guardianship granted? Yes No e. Whether there is a temporary guardianship 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. 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 child/ren spend time with each parental figure to: g. What has been your involvement regarding the care of the child/ren? h. If you want the current parenting plan to change, how would your proposed changes benefit the children? American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0007 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: Charge(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 : American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0007 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 4 SECTION 7 : 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 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 2. IF YES, what is your occupation, employer222s name, telephone number and employer222s address? 3. How long have 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 child(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 have gone to: Date : Doctor/Therapist n ame : Complete mailing a ddress : Telephone # : American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0007 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/06/19) Page 5 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 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 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 : Therapis