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 GUARDIANSHIP 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:_______________________ YOUR RELATIONSHIP TO THE CHILD(REN) :____________________________________________________________ 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: __________________________________________________________________________________________________ MARITAL STATUS: ( CIRCLE ONE ) SINGLE MARRIED DIVORCED SEPARATED WIDOWED LIVING TOGETHER NAME OF CURRENT SPOUSE/DOMESTIC PARTNER ____________________ LENGTH OF RELATION ____________ LIST NAMES AND AGES OF CHILDREN OF THIS RELATIONSHIP ___________________________________________ HEALTH ARE YOU RECEIVING MEDICAL TREATMENT? ( ) NO ( ) YES, BRIEFLY DESCRIBE __________________________ DOMESTIC VIOLENCE: WHERE THERE IS A HISTORY OF DOMESTIC VIOLENCE AND /OR A RESTRAINING ORDER IN EFFECT, THE PROTECTED PERSON MAY REQUEST SEPARATE MEDIATION UNDER FAMILY CODE 3181 AND/OR BRING A SUPPORT PERSON UNDER FAMILY CODE 6303. BRIEFLY DESCRIBE. __________________________________________________________________________________________________ __________________________________________________________________________________________________ _______I WISH TO HAVE SEPARATE MEDIATION _______I WISH TO HAVE A SUPPORT PERSON INFORMATION PERTAINING TO THE CHILD(REN) INVOLVED IN THIS CASE: WHO HAS CUSTODY OF THE CHILD(REN)?_____________________________________________________________ WHO SUPPORTS THE CHILD(REN)?___________________________________________________________________ IS THE CHILD(REN) SEEING THE PARENT(S) ( ) NO ( ) YES, IF SO WHAT IS THE VISITATION SCHEDULE?______ __________________________________________________________________________________________________ ARE THE ANY CURRENT CHARGES OF CHILD PHYSICAL /SEXUAL ABUSE OR NEGLECT?_____________________ __________________________________________________________________________________________________ IS THERE A HISTORY OR CURRENT ISSUE WITH DRUGS OR ALCOHOL? ___________________________________ ARE THERE ANY PROBLEMS RELATING TO THE SAFETY OF THE CHILD(REN)?______________________________ HAS CHILD PROTECTIVE SERVICES BEEN INVOLVED? _________________________________________________ HAS A PETITION BEEN FILED(W&I 300)?________________________________________________________________ HAVE THE CHILD(REN) WITNESSED DOMESTIC VIOLENCE?______________________________________________ CURRENT PROBLEMS_______________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 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-7 [REV. 05/05] www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com