SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO FAMILY COURT SERVICES 400 COUNTY CENTER, 6TH FLOOR REDWOOD CITY CA 94063 TEL: (650) 261-5080 FAX: (650) 261-5142 D.V INFORMATION SHEET DAY OF COURT MEDIATION CONFIDENTIAL YOUR NAME:_____________________________________________ CASE NUMBER____________________________ OTHER NAMES YOU HAVE USED:_____________________________________________________________________ BIRTHDATE:_____________________________BIRTHPLACE:_____________________________AGE:_____________ SOCIAL SECURITY NUMBER:________________________DRIVER'S LICENSE NUMBER:_______________________ HOME ADDRESS:___________________________CITY:_______________ ZIP CODE:______________STATE:______ MAILING ADDRESS:_________________________CITY:_______________ ZIP CODE:______________STATE:______ TELEPHONE #:HOME _____________________________ WORK/MESSAGE___________________________________ YOUR ATTORNEY:_______________________________________ TELEPHONE NUMBER:_______________________ CHILDREN INVOLVED IN THIS CASE: NAME ____________________________________ ____________________________________ ____________________________________ ____________________________________ DOB ________________________ ________________________ ________________________ ________________________ SCHOOL _________________________________ _________________________________ _________________________________ _________________________________ YOUR EMPLOYMENT INFORMATION: EMPLOYER_____________________________________________ADDRESS__________________________________ DATE EMPLOYED ______________________ WORK SCHEDULE ___________________________________________ JOB TITLE _______________________________ MONTHLY INCOME BEFORE TAXES __________________________ RESIDENCE HOW LONG IN YOUR PRESENT ADDRESS? _______________ ARE YOU MOVING? ( ) NO ( ) YES ____________ HOW MANY BEDROOMS? ________________ NUMBER OF PEOPLE IN YOUR HOME __________________________ ALL OTHERS RESIDING IN YOUR RESIDENCE AND THEIR RELATIONSHIP TO YOU: __________________________________________________________________________________________________ STATUS OF YOUR RELATIONSHIP WITH THE OTHER PARENT: MARRIED: ( ) YES ( ) NO , IF DIVORCED, DATE DIVORCE WAS FINAL: _____________________________________ DATE BEGAN LIVING TOGETHER: _____________________ DATE OF LAST SEPARATION: _____________________ NAME OF CURRENT SPOUSE/DOMESTIC PARTNER: _____________________________________________________ LIST NAMES AND AGES OF CHILDREN OF THIS RELATIONSHIP: ___________________________________________ HEALTH ARE YOU RECEIVING MEDICAL TREATMENT? ( ) NO ( ) YES, BRIEFLY DESCRIBE __________________________ DOMESTIC VIOLENCE: WHEN THERE IS A HISTORY OF DOMESTIC VIOLENCE OR A DOMESTIC VIOLENCE RESTRAINING ORDER, THE PROTECTED PERSON MAY REQUEST SEPARATE MEDIATION AND BRING A SUPPORT PERSON UNDER FAMILY CODES 3181 AND 6303. IF YOU HAVE A COPY OF YOUR DECLARATION OR RESTRAINING ORDER REGARDING DOMESTIC VIOLENCE, PLEASE PROVIDE A COPY TO THE MEDIATOR. PLEASE DESCRIBE WHEN, WHERE AND WHO WAS INVOLVED ________________________________________ ______________________________________________________________________________________________ LATEST INCIDENT ______________________________________________________________________________ WORST INCIDENT ______________________________________________________________________________ POLICE CALLED? EMERGENCY MEDICAL TREATMENT? WEAPONS_____________________________________ COURT INVOLVEMENT? TEMPORARY RESTRAINING ORDERS ISSUED? ________________________________ ANY COUNSELING OR HELP FROM DOMESTIC VIOLENCE AGENCY? ___________________________________ HAS CHILD PROTECTIVE SERVICES BEEN INVOLVED?______ _________________________________________ HAS A ( W & I 300) PETITION BEEN FILED?__________________________________________________________ HAVE THE CHILDREN WITNESSED DOMESTIC VIOLENCE ? ___________________________________________ CURRENT SITUATION: PLEASE LIMIT YOUR ANSWERS TO THE SPACE PROVIDED. WHAT CUSTODY/VISITATION PROBLEMS CURRENTLY EXIST? ___________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ REASONABLE SOLUTIONS __________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ I CERTIFY THAT ALL THE INFORMATION PROVIDED TO FAMILY COURT SERVICES IS TRUE AND CORRECT. I UNDERSTAND THAT FALSIFICATION OR OMISSION OF ANY INFORMATION MAY AFFECT THE DISPOSITION OF MY CASE, AND THAT THE FAMILY COURT SERVICES STAFF MAY CONSIDER ALL OTHER AVAILABLE FAMILY COURT SERVICES CASE INFORMATION REGARDING MYSELF. SIGNATURE ____________________________________________________ DATE ___________________________ FCS-6 [Rev. 05/05] www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com