Madera Superior Court Form Adopted for Optional Use MAD-FCS-0013 (Rev. 3/14/19) PETITIONER (S) SCR EENING FORM Page 1 of 1 MADERA COUNTY SUPERIOR COURT PETITIONER (S) SCREENING FORM PETITIONER(S)/NAME: CASE NUMBER: FCS File No. COURT DATE: DEPT: @ PETITIONERS RELATIONSHIP TO MINOR: CHILD/CHILDREN AT ISSUE: DOB DOB DOB NATURAL PARENTS: Mother 226 DOB Father 226 DOB Where is the minor residing at this time? With Petitioner With Parents Other: Mark the box that applies to the allegations in this petition: Domestic violence Substance abuse Child abuse Overall neglect Care taker absence Other: In the following questions, do not reveal the names of the reporting party who contacted CWS/CPS. That information shall be kept CONFIDENTIAL. Are you aware of any Child Welfare Service (CPS) complaints made against the parents? Yes No If so, are you aware of the outcome of such complaints? Yes No Are you aware of the names of the social workers? Yes No Were you referred to the Probate Court by a social worker? Yes No If Yes, what were the reasons given to you for such referral? Were you offered a Temporary voluntary case management plan through CWS to have custodial care of the minor at issue and told to file a Probate Guardianship by a certain date? Yes No If yes, please provide the court with a copy of the plan. Petitioner (s)/Attorney222s Signature Address Phone Number American LegalNet, Inc. www.FormsWorkFlow.com