ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FOR COURT USE ONLY FAX NO.(Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, COUNTY COURTHOUSE, 220 W. BROADWAY, SAN DIEGO, CA 92101 CENTRAL DIVISION, FAMILY COURT, 1555 6TH AVE., SAN DIEGO, CA, 92101 CENTRAL DIVISION, MADGE BRADLEY, 1409 4TH AVE., SAN DIEGO, CA 92101 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA, 92020 NORTH COUNTY DIVISION, 325 S. MELROSE DR., SUITE 340, VISTA, CA, 92081 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 PETITIONER(S) RESPONDENT(S) FAMILY COURT SERVICES SCREENING FORM CASE NUMBER (CONFIDENTIAL) FATHER Name: Address: Daytime Phone (8:00 a.m. to 5:00 p.m.): Attorney: Phone: MOTHER Name: Address: Daytime Phone (8:00 a.m. to 5:00 p.m.): Attorney: NOTE: Phone: THIS SCREENING FORM IS FOR FAMILY COURT SERVICES USE ONLY. CONFIDENTIAL. THIS INFORMATION WILL BE KEPT CHILDREN MAY NOT ACCOMPANY PARTIES TO MEDIATION UNLESS ORDERED BY THE COURT OR SPECIFICALLY REQUESTED BY MEDIATOR. FAILURE TO APPEAR OR FAILURE TO CANCEL THE MEDIATION APPOINTMENT AT LEAST 48 HOURS PRIOR TO THE APPOINTMENT TIME MAY RESULT IN SANCTIONS IMPOSED BY THE COURT OF UP TO $1500 TO ONE OR BOTH PARTIES PURSUANT TO CODE CIV. PROC. §177.5. Yes 1. 2. 3. 4 5. No Does any party allege domestic violence? Is there a domestic violence Temporary Restraining Order? Does any party require a Spanish-speaking counselor? Does any party living outside of the County of San Diego need phone mediation? Is a third party requesting custody or visitation? Grandparent Joinder Other: Name and relationship to child(ren) Date: Filing Party/Attorney Signature SDSC FCS-046 (Rev. 11/08) FAMILY COURT SERVICES SCREENING FORM (CONFIDENTIAL) American LegalNet, Inc. www.FormsWorkflow.com