VN163 FOR COURT USE ONLY IN THE MATTER OF: ________________________________________ CASE NUMBER: ____________________________________________ FAMILY COURT SERVICES INTAKE QUESTIONNAIRE 1. Previous Mediation Have the parents previously participated in child custody mediation? 2. Interpreters Required Is either parent non-English speaking or limited in speaking English? 3. Parent Change of Residence Has either parent recently moved or is planning to move out of the United States, State of California, or County of Ventura? 4. Domestic Violence Concerns* (a) Is there a Restraining or Protective order against either parent? (b) Have there been any allegations of violence, abuse, or stalking committed by either parent against the other or the child? 5. Children or Adult Protective Services Involvement Has either parent been contacted by a Children's or Adult Services Agency concerning an abuse/neglect investigation? 6. Child Custody Evaluation Have the parents participated or been ordered to participate in a child custody evaluation? When?: ______________________________ 7. Party in Jail or Prison Identify any parent who is expected to be in jail or prison at the time of the Mediation: ___________________________________ Name of parent incarcerated ______________________________ Facility YES NO 8. Dependency Petitions Have any dependency petitions been filed in Juvenile Court related to the parties children? _____________________________________________ Signature of Petitioner or Attorney for Petitioner ______________________ Date _____________________________________________ Signature of Petitioner or Attorney for Petitioner ______________________ Date *Family Code Section 3181(b) states; "If any party alleging domestic violence in a written declaration under penalty of perjury or a party protected by a protective order so requests, the mediator will meet with the parties separately and at separate times." THIS FORM TO REMAIN CONFIDENTIAL (Family Code §3177) Mandatory Form VN163 - Rev.7/09 FAMILY COURT SERVICES INTAKE QUESTIONNAIRE American LegalNet, Inc. www.FormsWorkFlow.com