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Family Court Services Intake Form

You have been referred to family court services for help with developing a parenting or visitation plan for the children in this case. The purpose of this intake form is to gather the information needed to assist the parties in coming to an agreement regarding the parenting decisions and shared parenting or visitation with the children; and to screen for any potential safety concerns. This form is for the mediator/recommending counselor's use only and will not be filed in the court case. Any paperwork you want considered by the Court must be filed separately with the Clerk of the Court.

All fields with an asterisk (*) are required

Child Custody Recommending Counseling and Voluntary Mediation Sessions will be held in private, and all written and verbal communication will be deemed “official information” (Evidence Code, §1040). Any information may, however, be disclosed to the court.

There are two types of mediation offered in Tulare County. If you are unsure of the type of appointment you have, contact Family Court Services for more information.

  • Child Custody Recommending Counseling (CCRC) – Court Ordered: The content of the session is not confidential from the Court. If the parties come to an agreement in session, the recommending counselor writes the agreement, the parties sign (if represented by an attorney, the attorney signs), and the judicial officer is provided the report for signature. Once the report becomes a Court Order, a copy of the report is provided to the parties and is filed in the public portion of the Court file.

    If there is not an agreement between the parties, the counselor prepares a report with recommendations to the Court which is filed in a Confidential section of the Court file and provided to the parties prior to the Court hearing. The report is confidential from everyone but the parties, the judicial officer, and some court staff.

  • Confidential (Voluntary) Mediation: The content of the session is confidential from everyone but the people in the session and their attorney’s. If the parties come to an agreement in the session, this agreement is written up and signed by the parties and their attorneys and then provided to the judicial officer for signature. The parties will be provided copies of the signed order. This report is filed in the public portion of the Court file. If the parties do not come to an agreement in session, no report is written for the Court. If a party desires to modify a custody and visitation order, the party will need to file a motion with the court and the parties may be sent to a court-ordered session at that time.

In both Child Custody Recommending Counseling and mediation, there are certain situations in which the mediator may reveal information without your permission. They are not required to inform you of their actions in this regard.

  • If you threaten to harm another person, if you threaten to harm yourself, or the mediator/recommending counselor has a reason to suspect child abuse/or neglect, the mediator/recommending counselor may contact the applicable person/protective agencies.

Case Information

Mandatory Orientation Prior to Mediation Session

Have you completed the required 30 minute video entitled: Orientation to Family Court Mediation and Child Custody Recommending Counseling?

If No, STOP and complete Part One of the orientation before continuing.

The following 2-3 hour Parenting After Separation Online Course is HIGHLY RECOMMENDED to prepare you for your session. This Course also provides a Certificate of Completion at the end and you may file this with the Court, although this is voluntary. https://pas.familieschange.ca.gov/

Is this your first time you have attended mediation in Tulare County?
Do you currently have a Court order for custody and visitation in Tulare County?
Do you have a full agreement with the other parent that you would like written up by the Court?
Do you currently have a Court order for custody and visitation in another County?

Personal Information

Distance Between Homes and Availability of Transportation

Distance between the home of the parties:
I have the following transportation available:

Employment

If unemployed, enter “unemployed”:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Your Attorney

Name Phone Number Fax Number

Minor Children in This Case

First Name Last Name Date of Birth Age School

Other People Living in Your Home

First and Last Name Age Relationship

Current Relationship

Do you and your current spouse, or partner, reside in the same home?

History of Relationship to Parent in this Case

If not married to the other parent, did you live together?

Well Being

Do the children have any special educational/emotional/health needs that could impact custody and/or visitation?

Safety

Do you have any safety concerns regarding the children spending parenting time with the other parent?
If No, proceed to the next section. If Yes, please mark the safety areas below:

Domestic Violence

Is there currently a Protective Order (Restraining Order or Criminal Protective Order) in effect protecting you, your children, the other parent, or the significant other of the other parent?

*THIS IS A REQUIRED FIELD
If No, proceed to the next section.

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

*THIS IS A REQUIRED FIELD
If no, proceed to the next section. If YES, please complete Part Three of this Orientation (on the previous page).

After reading Family Code Section 3044, please answer the following questions:

Family Code Section 3044

Pursuant to Family Code Section 3113 and 3181, are you requesting a separate mediation session due to a history of domestic violence between you and the other parent?

If yes, enter date of last incident 
If no, marking below indicates you are waiving your right to separate mediation session.

If there is a protective order in place, pursuant to Family Code Section 6303, are you requesting a support person be present during your session?

If no, marking below indicates you are waiving your right to having a support person present.
If yes, provide the name and relationship of the person. That person will sign a confidentiality agreement at the beginning of the session.

Criminal History

Have you ever been arrested, or been in jail or prison?

If Yes, please provide the arrest information below:
 

Date of Arrest County/State in Which Arrest Occurred Reason for Arrest Arresting Agency
Are you, under penalty of perjury, required to be registered as a sex offender under Section 290 of the Penal Code where the victim was a minor?
Is anyone else in your household, or your significant other required to be registered as a sex offender under Section 290 of the Penal Code where the victim was a minor?

Alcohol / Drug Abuse

Do you or have you ever abused the following:

Child Abuse

FAMILY CODE §3027: Monetary Sanctions for False Accusations of Child Abuse or Neglect. (a) If a Court determines that an accusation of Child Abuse or Neglect made during a child custody proceeding is FALSE at the time the accusation was made, the Court may impose reasonable monetary sanctions not to exceed ALL COSTS INCURRED BY THE PARTY ACCUSED AS A DIRECT RESULT OF DEFENDING THE ACCUSATION and reasonable attorney fees incurred in recovering sanctions against the person making the accusation. For the purpose of this section, “person” includes “a witness”, a “party” or a “party’s attorney.
 

Is there currently, or has there ever been, a reasonable suspicion of child abuse?

If Yes, please provide this information in the Incident table below. If no, proceed to the Parenting Plan And Strengths Assessment.
 

Has Juvenile Court filed a dependency petition for any of the children in this case?

 If Yes, when and for whom was dependency initiated?

Type of Abuse (check all that apply)
Was the Incident Reported to CPS or Police?
Type of Abuse (check all that apply)
Was the Incident Reported to CPS or Police?
Type of Abuse (check all that apply)
Was the Incident Reported to CPS or Police?

Parenting Plan and Strengths Assessment

What kinds of communication do you have with the other parent regarding the children? (Check all that apply)
Is this communication working?

Session Attendance Preferences

Do you prefer to attend your session (select all that apply)

When you select “Submit”, this intake form will be electronically sent to Family Court Services. You will also receive a confirmation email with a copy of your submitted intake form. This is confirmation that we received your email. Please check your spam and junk folders in your email in case the confirmation is sent there. When the Court ordered for you to attend Child Custody Recommending Counseling or Mediation, you were provided an information sheet with instructions on how to participate in your session (it has a QR code on it which led you to this orientation site).

Should your contact information change prior to your mediation session, you must notify Family Court Services immediately at: (559) 730-5000 Option 6. Failure to provide correct contact information may result in delays to your case.
 

 

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