SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE RI - FL024 Please note that the child custody recommending counseling process is confidential to the extent that information about your case will only be shared with those authorized to receive this information, which includes the court. The recommending counselor is also required by law to report to the Department of Public Social Se rvices or law enforcement reasonable suspicion of child abuse or neglect, or if any of the parties (including the children) present a danger to self or others. For Court Use Only CONFIDENTIAL DATE: CASE NAME: CASE NO: CHILD CUSTODY RECOMMENDING COUNSELING INTAKE QUESTIONNAIRE I. GENERAL INFORMATION Your Name: DOB: Age: (FIRST) (MIDDLE) (LAST) Current Address: City: State: Zip Code: How long have you lived at this address? Phone : ( ) Name of Employer: Work Location: Occ upation: Length of Employment: Work Schedule (Days/Times): Day(s) off: II. INFORMATION ABOUT THE CHILDREN INVOLVED IN THIS CASE Name Male/ Female Date of Birth Age Name of School and Hours of Attendance Grade Page 1 of 6 Adopted for Optional Use Riverside Superior Court RI - FL024 [Rev. 06/01/18 ] CHILD CUSTODY RECOMMENDING COUNSELING QUESTIONNAIRE riverside.courts.ca.gov/ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Child Custody Recommending Counseling Questionnaire - Cont inued RI - FL024 1. Is Child Protective Services (CPS) currently involved with your children? No Yes If yes, please explain: Social Worker Name: County: Telephone: 2. Have there ever been any Child Protective Services (CPS) referrals made regarding any of your children? No Yes If yes, please explain: 3 . Do any of your children have special educational, medical or emotional needs? No Yes If yes, please explain: 4 . Are any of your children in counseling? No Yes Past Current If yes, please explai n: How long have they been in counseling? How often do your children attend counseling? Telephone: 5. Are any of your children on medication? No Yes If yes, please explain: III. INFORMATION ABOUT OTHER CHILDREN LIVING IN YOUR HOME NOT INVOLVED IN YOUR CASE Name Male/ Female Age Relationship to you Page 2 of 6 Adopted for Optional Use Riverside Superior Court RI - FL024 [Rev. 06/01 /18 ] CHILD CUSTODY RECOMMENDING COUNSELING QUESTIONNAIRE riverside.courts.ca.gov/ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Child Custody Recommending Counseling Questionnaire - Cont inued RI - FL024 IV. INFORMATION ABOUT OTHER ADULTS LIVING IN YOUR HOME ( Please list a nyone other than your spouse/significant other) Name Date of Birth Age Relationship to you V. INFORMATION ABOUT YOU AND THE OTHER PARENT 1. What is your relationship with the other parent of the children involved in this case? ( Please check all that apply) a. We are currently married or registered domestic partners. b . We used to be married or registered domestic partners. c . We live together. d . We used to live together. e . We are dating or used to date. f . We were never in a committed relationship. g We were married. Date married: h . We are separated. Date separated: i . We are divorced. Date divorced: 2. Are you in a current relationship with some one other than the other parent? No Yes If yes, please answer the following: ( P lease check all that apply) a. We are currently married or registered domestic partners b. We are living together. c. We are dating but do not live together. d. We have children from this relationship. Na me of Spouse/Significant Other: Date of Birth: Age: 3. Do you or the other parent have any spec ial medical needs? No Yes If yes, please exp lain: 4. Are you or the other parent in counseling? No Yes If yes, please provide the following information: Telephone: Page 3 of 6 Adopted for Optional Use Riverside Superior Court RI - FL024 [Rev. 06/01 /18 ] CHILD CUSTODY RECOMMENDING COUNSELING QUESTIONNAIRE riverside.courts.ca.gov/ ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Child Custody Recommending Counseling Questionnaire - Cont inued RI - FL024 5. Have you or the other parent been hospitalized for psychiatric reasons? No Yes If yes, please explain: 6. Are you or the other parent taking any medication? No Yes If yes, please explain: 7. Is there drug or alcohol use by you or the other parent ? No Yes If yes, please explain: 8. Have you or the other parent ever been arrested or convicted of a crime? No Yes If yes, please explain (what charges were filed, what was the outcome of the charges, where were the charges filed , etc. ): VI. CUSTODY AND VISITATION PARENTING PLAN 1. Are there any existing custody and visitation orders regarding your chi ldren in Riverside County or in any other county or State? No Yes (if yes, explain below): Family Law Court County/State: Case No. Juvenile Court County/State: Case No. Other Court County/State: Case No. What are the orders? 2. How are you currently sharing the children with the other parent? Please explain the current time share schedule: 3. How would you like to share your children with the other parent? (DO NOT USE Percentages %) Please explain what schedule you think would be best for your children (be specific with days/times) Page 4 of 6 Adopted for Optional Use Riverside Superior Court RI - FL024 [Rev. 06/01 /18 ] CHILD CUSTODY RECOMMENDING COUNSELING QUESTIONNAIRE riverside.courts.ca.gov/ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Child Custody Recommending Counseling Questionnaire - Cont inued RI - FL024 VII. HISTORY OF DOMESTIC VIOLENCE If you do not feel safe meeting with the other parent and the recommending counselor together, please inform the clerk at the check - in window immediately. 1. Has there been a history of domestic violence between you and the other parent? No Yes If yes, please explain: 2. Is there a domestic violence or any other res training order type currently in effect? No Yes County/State Ordered: Case No. Date ordered: 3. Have the police or other law enforcement ever been called due to domestic violence between you and the other parent? No Yes If yes, please explain (how many times, was anyone arrested, where this occurred , etc. ): 4. Have you received medical care from a doctor or hospital because of injuries due to domestic v iolence between you and the other parent ? No Yes If yes, please explain: 5. Have any of your children been present when the domesti c violence occurred? No Yes If yes, please explain: If there is a history of domestic violence between you and the other parent, or you have a restraining order against the other parent, you are entitled to have a separate child custody recommending counseling session (separate from the other parent) and to have a support person with you during the child custody recommending counseling appointment and at the court hearing. The child custody recommending counselor will discuss with you the court rules and policies regarding the use of a support person during the session. I am willing to meet with the other parent together with the child custody recommending counselor. I am requesti ng to meet separately with the child custody recommending c ounselor. I declare under penalty of perjury that the information in this section regarding the history of domestic violence is true and correct. (SIGNATURE) (DATE) Page 5 of 6 Adopted for Optional Use Riverside Superior Court RI - FL024 [Rev. 06/01 /18 ] CHILD CUSTODY RECOMMENDING COUNSELING QUESTIONNAIRE riverside.courts.ca.gov/ocalfrms /localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Child Custody Recommending Counseling Questionnaire - Cont inued RI - FL024 Case No: VII I . Child C ustody Recommending Counseling reports are typically available to you two (2) days prior to your court hearing date. Please select how you would like to receive your Child Custody Recommending Counseling report: 1. I will pick up the report in person (photo ID required at the time of pick up) 2. I would like my report sent electronically: AUTHORIZATION FOR ELECTRONIC DELIVERY OF CCRC REPORTS I am the Petitioner Respondent Other: on the above referenced case and hereby give authorization to the Ri