CONFIDENTIAL SDSC FCS-002 (Rev. 12/18) FAMILY COURT SERVICES (FCS) DATA SHEET Page 1 of 3 Mandatory Form (CONFIDENTIAL) SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO FAMILY COURT SERVICES (FCS) DATA SHEET (CONFIDENTIAL) CHECK ONE Father Mother Grandparent Other (specify relationship): FULL LEGAL NAME AKA OR MAIDEN NAME ADDRESS Number and Street Apt. # City State Zip Code HOME TEL. NO. WORK TEL. NO. WORK SCHEDULE BIRTH DATE / / PLACE OF BIRTH LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER XXX 226 XX 226 DRIVER LICENSE NUMBER STATE CURRENTLY VALID Yes No ATTORNEY TEL. NO. Number and Street Apt. # City State Zip Code CHILD(REN)'S ATTORNEY (if any) TEL. NO. ADDRESS Number and Street Apt. # City State Zip Code PARENTS Date of Marriage or Date Began Living Together Date of Separation NAME OF MINOR CHILD(REN) First Middle Last Date of Birth Place of Birth residing 1. 2. 3. 4. COMPLETE ALL THREE PAGES Have you previously been to Family Court Yes No Case Name Case No. FCS Date Next Court Date IF YOU ARE BEING PROTECTED BY A RESTRAINING ORDER OR IF YOU ALLEGE DOMESTIC VIOLENCE, YOU MAY BE SEEN SEPARATELY. Are you requesting a separate session? Yes No If you want to be seen separately, advise the Family Court Services Clerk when you check in. SUPPORT PERSON: If you are being protected by a restraining order, a support person may accompany you during your FCS session. The support person must first sign a Family Court Services Domestic Violence Support Person Agreement (SDSC Form #FCS-038). Advise the Family Court Services Clerk of your support person when you check in. Are you requesting that your address and telephone number remain confidential? Yes No American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL CASE NAME CASE NUMBER SDSC FCS-002 (Rev. 12/18) FAMILY COURT SERVICES (FCS) DATA SHEET Page 2 of 3 Mandatory Form (CONFIDENTIAL) MEDICAL AND DENTAL INFORMATION Child(ren)222s Doctor's Name Tel. No. ADDRESS Number and Street Apt. # City State Zip Code List medical/dental information to be discussed at FCS EDUCATION Child Name of School Teacher/Counselor Grade 1. 2. 3. 4. COUNSELING Is Child(ren) Father Mother i Yes No Counselor for Counselor for Counselor's Name Counselor's Name Address Address Tel. No. Tel. No. CHILD(REN)222S ACTIVITIES AND OTHER SPECIAL NEEDS (e.g. special classesteam activities and transportation to and from these activities) 1. Are there allegations of verbal intimidation or threats Yes No 2. Has there been physica Yes No 0 226 6 mos. 6 mos. 226 1 yr. 1 yr. or more 3. been involved Yes No Provide details: 4. Have there been allegations of verbal intimidation/threatsphysical estraining orders yourself and your parent current spouse or cohabitant party in dating or engagement relationship o Yes No If yeshat apply. Provide details: 5. Have there been allegations of abuse against your child(ren) or child(ren) have provided care Yes No Has Child Welfare Services (CWS) Yes No CWtelephone number American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL CASE NAME CASE NUMBER SDSC FCS-002 (Rev. 12/18) FAMILY COURT SERVICES (FCS) DATA SHEET Page 3 of 3 Mandatory Form (CONFIDENTIAL) FAMILY COURT SERVICES (FCS) DATA SHEET Complete the following questions. 1. W 2. 3. Is there a court o Yes No a. If b. 4. If there is no court order or a different schedule: 5. Date: Signature of Party Filling Out This Form NO ATTACHMENTS American LegalNet, Inc. www.FormsWorkFlow.com