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Domestic Violence Questionnaire

You have indicated there is domestic violence in your case. Pursuant to CA Rules of Court 5.210 and 5.215, we are requesting you answer the following questions as this assists the mediator with safety screening for your family. This form is for the mediator’s use and will not be filed in the court file or accessible to the other party.
All fields with an asterisk (*) are required

Case Information

Personal Information

Has there ever been any police involvement and/or arrests related to domestic violence between you and the other parent?
Date Location/ City of Incident Reason for Arrest or Police Involvement Police Report Number Arresting Agency Charges Filed
Were your children present during the violence?
Were any Weapons Involved?
Does the other party have access to firearms or weapons?
Was medical attention required?
Within the past year, has the frequency:

Please check any of the types of violence below which have occurred or the other party has threatened to do:
Has either party threatened or tried to commit suicide?
Are you currently afraid of the other parent for any reason?

Please see the following link for Safety Planning for you and your family: https://www.courts.ca.gov/1263.htm

The mediator/ recommending counselor will contact you privately by telephone prior to your session to review your responses and discuss the safest way to proceed with your session. 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.
 

Session Attendance Preferences

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

I declare under penalty of perjury, under the laws of the State of California, that I have read the information contained herein and the information provided is true and correct.
 

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.