ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO.(Optional): 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 (CONFIDENTIAL) FATHER Name: Address: Daytime Telephone Number (8:00 a.m. to 5:00 p.m.): Attorney: MOTHER Name: Address: Daytime Telephone Number (8:00 a.m. to 5:00 p.m.): Attorney: CASE NUMBER Telephone Number: Telephone Number: NOTE: THIS SCREENING FORM IS FOR FAMILY COURT SERVICES (FCS) USE ONLY. THIS INFORMATION WILL BE KEPT CONFIDENTIAL. CHILDREN MAY NOT ACCOMPANY PARTIES TO THE FAMILY COURT SERVICES APPOINTMENT UNLESS ORDERED BY THE COURT OR SPECIFICALLY REQUESTED BY A FAMILY COURT SERVICES COUNSELOR. FAILURE TO APPEAR OR FAILURE TO CANCEL THE FAMILY COURT SERVICES 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 AND SAN DIEGO SUPERIOR COURT LOCAL RULES. Yes No 1. 2. 3. 4 5. Do you or the other party allege domestic violence? Is there a domestic violence restraining order? Do you or the other party require a Spanish-speaking counselor? Do you or the other party live outside of the County of San Diego and need a telephone FCS session? Is a third party requesting custody or visitation? Grandparent Joinder Other: Name and relationship to child(ren) Signature of Filing Party/Attorney Date: FAMILY COURT SERVICES SCREENING FORM (CONFIDENTIAL) American LegalNet, Inc. www.FormsWorkFlow.com SDSC FCS-046 (Rev. 8/11)