SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE RI - PR091 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: PROBATE - 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 4 Adopted for Optional Use Riverside Superior Court RI - PR091 [Rev. 06/01 / 18] PROBATE - CHILD CUSTODY RECOMMENDING COUNSELING QUESTIONNAIRE riverside.courts.ca.gov/ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Probate - Child Custody Recommending Counseling Questionnaire - Cont inued RI - PR091 1. Do any of the children have special educational, medical, or emotional needs? No Yes If yes, please explain: 2. Are any of the children in counseling? No Yes Past Current If yes, please explain: How long have they been in counseling? How often do the children attend counseling? Telephone: 3 . Are any of the 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 IV. INFORMATION ABOUT OTHER ADULTS LIVING IN YOUR HOME Name Date of Birth Age Relationship to you 1. Are you or the other party in counseling? No Yes If yes, please provide the following information: Telephone: Page 2 of 4 Adopted for Optional Use Riverside Superior Court RI - PR091 [Rev. 06/01 /18 ] PROBATE - CHILD CUSTODY RECOMMENDING COUNSELING QUESTIONNAIRE riverside.courts.ca.gov/ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Probate - Child Custody Recommending Counseling Questionnaire - Cont inued RI - PR091 2 . Have you or the other party been hospitalized for psychiatric reasons? No Yes If yes, please explain: 6. Are you or the other par ty taking any medication? No Yes If yes, please explain: 7. Is there drug or alcohol use by either party? No Yes If yes, please explain: 8. Have you or the other party 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. ): V . VISITATION PLAN 1 . Are you currently sharing the children? Please explain the current schedule: 2 . What visitation plan do you propose? Please explain what schedule you think would be best for the children (be specific with days/times) : Page 3 of 4 Adopted for Optional Use Riverside Superior Court RI - PR091 [Rev. 06/01 /18 ] PROBATE - CHILD CUSTODY RECOMMENDING COUNSELING QUESTIONNAIRE riverside.courts.ca.gov/ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com Probate - Child Custody Recommending Counseling Questionnaire - Cont inued RI - PR091 Case No: VI . Child Custody Recommending Counseling r eports are typically available two (2) days prior to the hearing date. Please select how you would like to receive your Child Custody Recommending Counseling report: 1. I will pick u p the report in person (photo identification is required) 2. I would like my report sent electronically: AUTHORIZATION FOR ELECTRONIC DELIVERY OF CCRC REPORTS I am the Parent Guardian Other: on the above referenced case and hereby give authorization to the Riverside Superior Court to send my Child Custody Recommending Counseling (CCRC) reports to the person(s) indicated below electronically using the following method(s): a. E - Mail i. Name of Recipient: Email Address: ii. Name of Recipient: Email Address: b. Facsimile i. Name of Recipient: Fax Number: ii. Name of Recipient: Fax Number: I give the Riverside Superior Court authorization to send my Child Custody Recommending Counseling (CCRC) reports electronically. ( DATE ) ( SIGNATURE ) Page 4 of 4 Adopted for Optional Use Riverside Superior Court RI - PR091 [Rev. 06/01 /18 ] PROBATE - CHILD CUSTODY RECOMMENDING COUNSELING QUESTIONNAIRE riverside.courts.ca.gov/ocalfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com