FAMILY INFORMATION FORM AND URGENT CONCERNS This form must be completed with any petition and response in any family law, domestic violence or probate guardianship action INVOLVING MINOR CHILDREN. This form, once completed, is a confidential document. It is not available for public viewing, but it can be viewed by the judge, the mediator, your attorney, the opposing attorney, or the other party. Case Number: □First filing of this form □ Subsequent filing of this form TELL US ABOUT YOURSELF AND THE OTHER PARTY TO THIS ACTION Your Last Name Middle Name First Name Date of Birth Other Party’s Last Name Middle Name First Name Date of Birth Other names that you or the other party have used (for example, names from prior marriages or alias): CHILDREN 1. Has there ever been court papers filed asking for custody of the children of this marriage or relationship? □ YES □ NO If YES, in which state and county? __________________________________________ 2. Have you requested the services of the Department of Child Support Services (DCSS)? □ YES □ NO If YES, when? ____________ 3. Are you receiving or have applied for welfare? □ YES □ NO If YES, when? _________________ PLEASE LIST BELOW ALL BIOLOGICAL CHILDREN, STEP CHILDREN, ADOPTED CHILDREN AND THOSE WITH WHOM YOU HAVE LEGAL GUARDIANSHIP. First Last Name Date of Birth Sex □ □ □ □ M M M M Do you have an order giving you full or partial custody of this child? □ □ □ □ F F F F PLEASE LIST NAMES OF OTHER ADULTS LIVING IN YOUR HOME. First Last Name Date of Birth Sex □ □ □ Page 1 of 2 Rev. 08-07 M M M Relationship to you □ □ □ F F F American LegalNet, Inc. www.FormsWorkFlow.com URGENT CONCERNS Domestic Violence, Child Kidnapping, Child Sexual Abuse, Health, Schooling, Delinquency □ □ □ □ YES NO 1. Are you currently afraid of the other parent or anyone else living in the home for any reason? If yes, what is your concern? (use the back side of this form if necessary) __________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 2. Do you have concerns about the health, safety, or schooling of any children living in the home? YES NO S If yes, what is your concern? (use the back side of this form if necessary) __________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ l □ YES □ NO 3. Has Child Protective Services ever contacted you about any of your children? 4. Do you have, or are you asking for, a domestic violence restraining order? □ YES □ NO 5. An interpreter may be available for domestic violence matters. Do you need an interpreter? □ YES □ NO If YES, for what language? _______________________________________________ COURT AND POLICE ACTIONS □ □ Have you ever been convicted of a crime and/or put in jail or prison? YES NO If yes, please explain ___________________________________________________________________________________________________ Are there any other cases that involve you or your family in THIS county? Name of Case □ YES □ NO If yes, please complete: Case Number Are there any other cases that involve you or your family in ANOTHER COUNTY OR STATE? If yes, please complete: Name of Case Case Number County □ YES □ NO State _________________________________________________________________________________________________ Signature Date _________________________________________________________________________________________________ Mediator Signature Page 1 of 2 Rev. 08-07 Date American LegalNet, Inc. www.FormsWorkFlow.com