MAD-FCS-0011 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/07/19) 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 #: NEXT COURT DATE: FCS #: SECTION 1: GUARD IAN INFORMATION : 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: *NOTE: REPORTS WILL BE E - MAILED TO YOU AT THE E - MAIL ADDRESS YOU PROVIDE ABOVE . NAME OF EMPLOYER : (if unemployed write 223unemployed224) WORK SCHEDULE EACH DAY (start time and end time): SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY W ho watches the chi ld/ren when you are unavailable? Please give their name and telephone #: SECTION 2 : NATURAL MOTHER 222S INFORMATION (FILL OUT AS BEST YOU CAN) : PARENT222S N AME (Last, First) : ADDRESS OF NATURAL PARENT : CITY : STATE : ZIP CODE : DATE OF BIRTH : TEL EPHONE # : EMAIL ADDRESS : NAME OF EMPLOYER : (if unemployed write 223unemployed224) WORK SCHEDULE EACH DAY (start time and end time): SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SECTION 3 : NATURAL FATHER 222S INFORMATION (FILL OUT AS BEST YOU CAN): PARENT222S N AME (Last, First): ADDRESS OF NATURAL PARENT: CITY: STATE: ZIP CODE: DATE OF BIRTH: TEL EPHONE # : EMAIL ADDRESS : NAME OF EMPLOYER : (if unemployed write 223unemployed224) WORK SCHEDULE EACH DAY (start time and end time): GUARDIANSHIP MEDIATION INTAKE / QUESTIONNAIRE Revised February 2019 American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0011 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/07/19) Page 2 SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SECTION 4 : 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 visitation order? Yes No If Yes, what is it? 3. 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 each parent to: 4. If you want the current visitation plan to change, how would your proposed changes benefit the child/ren? SECTION 5 : INVOLVEMENT BETWEEN THE NATURA L PARENT AND CHILD/REN (DO NOT LEAVE BLANK) : a. What has been your /the natural parent(s) involvement regarding the care of the child/ren? 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) been involved with your family for allegations of child abuse or neglect? Yes No If yes, when and what was the outcome? SECTION 7: INFORMATION ABOUT YOUR CURRENT BOYFRIEND, GIRLFRIEND, OR SPOUSE: Full name: Date of birth: Social Security #: Other names used: Driver222s license #/State: Date relationship began : American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0011 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/07/19) Page 3 Home phone number: Cell phone number: Occupation: Present employer: Employer222s phone #: Days/Hours worked: SECTION 8: ADDITIONAL INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com MAD-FCS-0011 Form Adopted for Mandatory Use Superior Court of Madera County (Rev. 3/07/19) Page 4 American LegalNet, Inc. www.FormsWorkFlow.com