SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO MEDIATION DATA SHEET (CONFIDENTIAL) Case Name _____________________________ PLEASE COMPLETE ALL THREE PAGES Case No. _____________________________ Have you previously been to Family Court Services? Yes Mediation Date _________________________ No 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 Are you requesting that your address and phone number remain confidential? Yes No If you desire to be seen separately, please advise the Family Court Services Clerk when you check in. CHECK ONE Father Mother Grandparent Other: specify relationship AKA OR MAIDEN NAME FULL LEGAL NAME ADDRESS Number and Street HOME PHONE Apt. #. WORK PHONE DRIVER LICENSE NUMBER State Zip Code WORK SCHEDULE BIRTH DATE SOCIAL SECURITY NUMBER City / / PLACE OF BIRTH STATE CURRENTLY VALID Yes No ATTORNEY _____________________________________________________ PHONE ADDRESS Number and Street Apt. #. City State Zip Code CHILD(REN)'S ATTORNEY (if any) ____________________________________ PHONE _________________________ ADDRESS Number and Street Apt. #. City State Zip Code PARENTS Date of Marriage ______________ or Date Began Living Together ______________ Date of Separation _____________ If dissolution fıled, when? _____________________________ NAME OF MINOR CHILD(REN) Parent with First Middle Last Date of Birth Place of Birth whom residing 1. 2. 3. 4. SDSC FCS-002 (Rev. 4/09) MEDIATION DATA SHEET (CONFIDENTIAL) Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com CASE NAME CASE NUMBER MEDICAL AND DENTAL INFORMATION Child(ren) Doctor's Name PHONE ADDRESS Number and Street Apt. #. City State Zip Code Please list medical/dental information to be discussed in mediation: EDUCATION Child Name of School Teacher/Counselor Grade 1. 2. 3. 4. COUNSELING Child(ren) Is Father Mother in Counseling? Yes No Counselor for Counselor for Counselor's Name Counselor's Name Address Address Phone Phone When did counseling begin? When did counseling begin? (Such as special classes, team activities, transportation to CHILD(REN)’S ACTIVITIES AND OTHER SPECIAL NEEDS and from these activities) 1. Are there allegations of verbal intimidation or threats? Yes No 2. Has there been physical violence between the parents? Yes No If yes, how long ago? 0 - 6 mos. 3. Has law enforcement been involved? 6 mos. - 1 yr. Yes 1 yr. or more No Please provide details: 4. Have there been allegations of abuse against the child(ren)? Yes No a. If yes, when: b. Who made the allegations? c. Who was the alleged abuser? d. Has Child Protective Services (CPS) been involved? Yes No e. CPS worker's name and phone number SDSC FCS-002 (Rev. 4/09) MEDIATION DATA SHEET (CONFIDENTIAL) Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com CASE NAME CASE NUMBER MEDIATION DATA SHEET Please complete the following questions. 1. Which parent filed the current court action? 2. What is the action regarding? 3. Is there a court order regarding custody and visitation now? Yes No a. If yes, briefly summarize: b. When was it issued? 4. If there is no court order or a different schedule is being practiced, please summarize your current parenting schedule. 5. What parenting schedule would you like to have? Date: Signature of Party Filling Out This Form NO ATTACHMENTS PLEASE SDSC FCS-002 (Rev. 4/09) MEDIATION DATA SHEET (CONFIDENTIAL) Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com