SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO FAMILY COURT SERVICES 400 COUNTY CENTER, 6TH FLOOR REDWOOD CITY, CA 94063 TEL: (650) 363 4561 FAX: (650) 363 4966 INFORMATION SHEET - MEDIATION & EVALUATION SERVICE CONFIDENTIAL Failure to complete this form will delay your appointment, bring completed form with you. Please limit your answers to the space provided. COURT #________________ Your name: ______________________________________________________________________ Other names you have used: _________________________________________________________ Birthdate: _________________ Birthplace____________________________ Age:______________ Social security number: __________________ Driver's license number: ____________________ Home address: ____________________________________________________________________ City________________________________________State_____________Zip code_____________ Mailing address: ___________________________________________________________________ City________________________________________State______________Zip code_____________ Telephone # :home____________________________ Work/message_________________________ Attorney’s name: __________________________________________________________________ Address: _________________________________________________________________________ City________________________________________State______________Zip code_____________ Telephone number____________________________Fax number____________________________ Children involved in this matter: Name: _____________________DOB: ____________ Name: _____________________DOB: ____________ Name: _____________________DOB: ____________ Name: _____________________DOB: ____________ Age: _________Lives with_______________ Age: _________Lives with_______________ Age: _________Lives with_______________ Age: _________Lives with_______________ Residence: How long in your present address?__________ Rent or Own Number of persons in home: ________ Number of bedrooms: ___________ Are you planning to move? ( )No ( ) Yes: __________________ All others residing in your current residence: Their relationship to you (including children.) _________________________________________________________________________________ _________________________________________________________________________________ Your employment information: Employer: __________________________________Address: _______________________________ Date employed: ________________ days/hours of work: ___________________________________ Job title: ___________________________________Monthly income before taxes: _______________ 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: ___________________ Other marriages: Name(s): ____________________________________________date(s): _______________________ Children from those marriages: ________________________________________________________ Health: Are you presently receiving any medical treatment? ( ) No ( ) Yes: briefly describe: ______________ _________________________________________________________________________________ Domestic Violence: If not applicable, skip this section & continue with * CURRENT SITUATION. 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 & 6303 _____I request separate mediation under code section 3181 _____I wish to bring a support person under code section 6303 FCS-4 [Rev.05/05] Page 1 of 2 www.sanmateocourt.org American LegalNet, Inc. www.USCourtForms.com History and Background of Domestic Violence: If there is a history of violence against you or the children please describe when, where and who was involved? _________________________________________________________________________ _________________________________________________________________________________ If you have a copy of your declaration or restraining order regarding Domestic Violence, please provide a copy to the mediator. Otherwise, please briefly answer the following: Latest incident:________________________________________________________________ ______________________________________________________________________________ Worst incident:________________________________________________________________ ______________________________________________________________________________ Police called? emergency medical treatment? weapons involved? _______________________ ______________________________________________________________________________ ______________________________________________________________________________ Court involvement? Temporary restraining orders issued? _____________________________ ______________________________________________________________________________ Any counseling or help from domestic violence agency? _______________________________ Has Child Protective Services been involved?____ ___________________________________ Have the children witnessed the Domestic Violence occurring?__________________________ ______________________________________________________________________________ * Current situation: Please limit your answers to the space provided. Are the children seeing the other parent? ___________________________________________ Do you or the other parent have any history or current issues with drug/alcohol abuse?_______ ____________________________________________________________________________ Are there any current charges of child physical abuse, sexual abuse or neglect? ____________ ____________________________________________________________________________ Has a dependency petition (W&I 300) been filed?_____________________________________ Are there any problems relating to the safety of the children? ___________________________ What hours of the day, days of the week, or week of the month do you spend time with or see your children? ________________________________________________________________ ___________________________________________________________________________ What custody/visitation problems currently exist? __________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Please list some reasonable solutions to those problems: ___________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ******************************************************************************************************************** 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____________________ • If you are submitting copies of any documents, please bring an additional copy for the other party. FCS-4 [Rev. 05/05] Page 2 of 2 www.sanmatteocourt.org American LegalNet, Inc. www.USCourtForms.com