PFC-15 R07-17 FAMILY COURT SERVICES TIER 1 PACKET Page 1 of 5

SUPERIOR COURT OF CALIFORNIA · COUNTY OF FRESNOFAMILY COURT SERVICES

1130 ‘O’ Street Fresno, CA 93721

(559) 457-2100 (option #4)www.fresno.courts.ca.gov/family/family_court_services.php

Family Court Services Tier 1 Intake Form

Orientation: Completion of the Online FCS Orientation is ordered by the Court and

is essential to your success in the Mediation session. TheOrientation will provide information about your upcoming mediationappointment.

You can view the complete FCS audio and visual slide show OrientationOnline at www.fresno.courts.ca.gov/family/family_court_services.php.

The same online slide show will be shown in the FCS lobbyevery Friday at 1:00pm in English and at 2:30pm in Spanish.

Tier 1 Mediation:

Date: Time: 8:00am, 10:00am and 1:00pm

Located on the 1st floor of the B.F. Sisk Courthouse, Family Court Services, #102.

Return Court Date:

Date: Time: Department:

Please read this ENTIRE packet very carefully. This packet must be completed PRIOR to YOUR MEDIATION

APPOINTMENT

The mediator will use this FCS Intake Form to familiarize themselves with yourfamily and to be better prepared to meet your needs during the mediationsession.

The FCS Intake Form will NOT be shared with the Judicial Officer or the otherparties on the case.

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Family Court Services Tier 1 Intake Form

Purpose of Mediation: The Family Court Services Mediator can help parties formulate a parenting plan regarding the

following issues: How the children will spend time with each party (regular time and holidays) How the parties will make legal decisions about the children How the children will be transported and exchanged for the visits Participation in programs or services that may beneficial for the family Safety Considerations

Although parents are expected to actively participate in the mediation process, parents are in NO WAY obligated to agree to a parenting plan during mediation.

Financial considerations including division of property, child support and spousal support arenot addressed in Family Court Services Mediation.

Confidentiality: Pursuant to Family Code §3188, Mediation is private and confidential. The mediator may not

make a recommendation as to custody or visitation to anyone other than the parties participatingin the mediation appointment. Other than reporting the parties’ agreement to the Court, themediator will not disclose what occurred in mediation with the following exceptions: If the Mediator determines there is reasonable suspicion of danger to one of the parties

or others, the mediator is required to report suspected child abuse, elder abuse, and/or ifsomeone is a danger to themselves or others to the appropriate agency.

In the event of a partial agreement the Mediator will report the partial agreement to theCourt. In addition, a list, in neutral terms, of the unresolved issues may be provided tothe Court with consent from all parties.

Documents: The Family Court Services Mediator has access to documents filed with the Court. The Mediator

may discuss documents provided by the parents during the mediation session, for the solepurpose of facilitating an agreement between the parties regarding custody and visitation. TheMediator will NOT retain any documents presented by the parties during the Tier I mediation.

Interpreters: If you do not speak English, you must bring your own interpreter to your mediation

appointment. Failure to bring your own interpreter may result in cancellation of your Mediationappointment.

Si usted no habla Inglés, usted debe traer su propio intérprete. La falta de traer su propio

intérprete puede resultar en la cancelación de su Mediación de custodia de los hijos.

Parents have an obligation to meaningfully participate in mediation. A failure to meaningfullyparticipate in mediation may result in that parent not being heard on issues of custody/visitation before the Court. Family Court Services may inform the Court of your level of participation. Any attorney who knowingly frustrates inplementation of mediation may be reported to the State Bar for disciplinary proceedings. (Bach v. State Bar (1987( 43 Cal.3rd 848,852-853)

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Separate Sessions: Pursuant to Family Code §3181, where there has been a history of domestic violence

between the parties or where a protective order as defined in §6218 is in effect, at therequest of the party alleging domestic violence in a written declaration under penalty ofperjury or protected by the order, the Mediator appointed pursuant to this chapter shall meetwith the parties separately and at separate times.

If you feel that separate sessions are appropriate due to a history of domestic

violence, please contact Family Court Services IMMEDIATELY to complete a

“Request for Separate Sessions”. This request should be submitted to Family Court

Services at least five days prior to your Mediation appointment.

Common Terms: Sole Legal Custody – one parent has the right and responsibility to make decisions related to

the health, education and welfare of the child. Sole Physical Custody – a child shall reside with and be under the supervision of one parent,

subject to the Court ordering visitation for the other parent. Sole physical custody is ordered incases when one parent has limited contact with the children, typically less than 33%.

Joint Legal Custody – both parents share the right and responsibility to make decisionsrelated to the health, education and welfare of the child.

Joint Physical Custody – each parent has significant periods of time with the child. Jointphysical custody shall be shared in such a way as to assure a child of frequent and continuingcontact with both parents. However, joint physical custody does not always mean equal timewith both parents.

For additional information: www.fresno.courts.ca.gov/family/family_court_services.php

email: FresnoFCS@fresno.courts.ca.gov

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SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO

Case Number:

FAMILY COURT SERVICES TIER 1 INTAKE FORM

PERSONAL INFORMATION

Name: Other Names Used:

(First) (Middle) (Last) (Nickname, Aliases, Maiden Name)

Address: City:

(Number and Street Name) (Apartment No.)

State: Zip: County:

Phone Number(s): ( ) ( ) Date of Birth: (Home) (Work / Cell)

OTHER PARENT / PARTY’S PERSONAL INFORMATION

Other Parent’s / Party’s Name: Date of Birth:

(First) (Middle) (Last)

EMPLOYMENT

Employer (if unemployed, Please Write “Unemployed”):

Work Schedule: MON TUES WED THURS FRI SAT SUN Work Hrs:

ATTORNEY

Name: Phone Number:

MINOR CHILDREN IN THIS CASE

Name DOB School Name DOB School

OTHER ADULTS IN YOUR HOME

Name DOB Relationship Name DOB Relationship

DOMESTIC VIOLENCE

Yes No

Yes No

1. Is there currently a Restraining Order in effect protecting you or the other parent?

Expiration date:

2. Are you, under penalty of perjury, alleging that there is a history of domestic violence between youand the other parent?

3. If you answered YES to question #2:

4. Are you requesting a separate mediation session due to a history of domestic violence

between you and the other parent? Yes No

If YES to #4, would you like for the FCS staff to provide you with information about creating a Safety Plan:

Yes No

If you answered ‘YES’ to questions #2 and #4, please immediately contact Family Court Services or go to the FCS website to receive a packet regarding your request for separate mediation sessions.

AM/PM

Were the child/ren present during the violence? Yes No

Was medical attention required? Yes No

Yes No Was Law Enforcement involved?Yes No Were any weapons involved?

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QUESTIONNAIRE

1. Do you currently have a Court order for custody and visitation: Yes No

Describe how much time each parent has with the child/rensince your separation.

2. Please provide 2 detailed visitation options, including specific days and times for exchanges

Visitation schedule 1: Sole Legal Sole Physical Joint Legal Joint Physical

Thanksgiving: Christmas:

Holiday Schedule:

Easter:

Visitation schedule 2: Sole Legal Sole Physical Joint Legal Joint Physical

Holiday Schedule:

Easter: Thanksgiving: Christmas:

3. Approximately, now many miles to you reside from the other parent?

4. Major areas of concern that would justify limited contact between the child/ren and the other parent:

Substance abuse

Child/ren’s resistance to visitation

Neglect of medical care

Use of inappropriate discipline

Exposure to criminal behavior/Arrest History

Child/ren’s poor academic performance

History of child abuse / CPS / Police involvement

Unavailability of other parent to care for the child/ren

Briefly summarize the concerns you have regarding the custody and/or welfare of the child/ren:

Do the child/ren have any special needs that could impact custody/visitation?

SIGNATURE

I declare that the foregoing information, as provided in this entire form, is true and correct.

(Date) (Signature)