Form Adopted for Use www.placer.courts.ca.gov Superior Court of California, County of Placer Form No. PL-FCS006 Effective 0--201 SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF PLACER FAMILY COURT SERVICES REFERRAL INFORMATION SHEET Date: Case Number: PARENT Name (Please print) Date of Birth PARENT Name (Please print) Date of Birth Mailing Address Mailing Address City, State, Zip Code City, State, Zip Code Telephone Number (where a message may be left): Telephone Number (where a message may be left) Email Address Email Address Confirm Email Address Confirm Email Address Attorney222s Name State Bar # Attorney222s Name State Bar # Attorney222s Full Address Attorney222s Full Address Attorney222s Telephone Number Attorney222s Telephone Number Attorney222s Email Address Attorney222s Email Address Full Names of Minor Children Age Birthdate Primary Residence(s) Name of School . (To list additional children, use back of this form) Please list any other child custody cases involving the child(ren) filed in Placer County or any other Court, including Domestic Violence, Guardianship and/or Juvenile matters. You may also list criminal cases or other court cases that you feel are important for Family Court Services to know. Case no. Title of case: Case no. Title of case: Case no. Title of case: (Continue on the other side to list any additional cases) Please answer the following questions: 1.Has there been any domestic/family violence or abuse by or with the other parent? 2.Is there a restraining order in place right now? 3.Do you wish to meet separately from the other parent? Yes No Not Sure Yes No Not Sure Yes No Not Sure American LegalNet, Inc. www.FormsWorkFlow.com