SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE RI - JV032 DATE: For Court Use Only CONFIDENTIAL CASE NAME : CASE NO : JUVENILE CHILD CUSTODY RECOMMENDING COUNSELING INTAKE QUESTIONNAIRE Please note that the juvenile mediation 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 c ounselor is also required by law to report to the Department of Public Social Services 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. I. GENERAL INFORMATION Your Name: DOB: Age: (FIRST) (MIDDLE) (LAST) Do you have any issues that would impair your ability to transport the minor for visitation? YES NO (If yes, please explain below): 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) : Days off: Page 1 of 2 Adopted for Optional Use Riverside Superior Court RI - JV032 [Rev. 05/11/18 ] JUVENILE CHILD CUSTODY RECOMMENDING COUNSELING INTAKE QUESIONNAIRE riverside.courts.ca.gov/ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com II. INFORMATION ABOUT THE CHILDREN INVOLVED IN THIS CASE Name Male/ Female Date of Birth Age Name of School and Hours of Attendance Grade III. INFORMATION ABOUT OTHER CHILDREN LIVING IN YOUR HOME NOT INVOLVED IN YOUR CASE Name Male/ Female Date of Birth Age Relationship to you IV. INFORMATION ABOUT OTHER ADULTS LIVING IN YOUR HOME ( Please list a nyone other than your spouse/significant other) Name Age Date of Birth Relationship to You V . CUSTODY AND VISITATION PARENTING PLAN 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 2 of 2 Adopted for Optional Use Riverside Superior Court RI - JV032 [Rev. 05/11 /18 ] J UVENILE CHILD CUSTODY RECOMMENDING COUNSELING INTAKE QUESIONNAIRE riverside.courts.ca.gov/ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com