Case Number:
Next Hearing Date (mm/dd/yyyy):
in Dept.
INFORMATION ABOUT YOU:
Your Name:
Date of Birth (mm/dd/yyyy):
Cell Phone#:
E-mail:
Address:
Full address includes Number, Street, (Apt.), City, State, and Zip.
I need an interpreter
Yes
(language)
No
Occupation:
Type of Employment: Employer:
Work Hours: Work Phone#:
Attorney:
Name:
Address:
Phone Number:
I HAVE VIEWED THE ORIENTATION VIDEO ONLINE CALLED "OUR CHILDREN FIRST"?
Yes,
Date (mm/dd/yyyy)
No
If a history of domestic violence and/or a Protective/Restraining Order exists, clients will be interviewed separately
(unless otherwise indicated by mediator).
DO YOU REQUEST AN INTERVIEW SEPARATE FROM THE OTHER PARENT?
No
Yes
-------------------- PLEASE REVIEW EACH STATEMENT BELOW AND CHECK THE BOXES THAT APPLY ------------------------------
|
No |
Yes |
One or more of the following has occurred in your relationship: Slapping, Punching, Choking,
Kicking, Shoving, Grabbing, Forced Sex, Threats of (describe),
or Other Violence
(describe)
﹍ The violence occurred:
Less than one year ago
More than one year ago
﹍ The violence occurred:
Once between the parties
More than once between the parties
|
| No |
Yes |
The children have been physically injured by either you or the other party. |
| No |
Yes |
The Department of Children and Family Services (DCFS or CPS) is currently, or has been, involved
with your children. |
| No |
Yes |
The police or other law enforcement have been involved with you or the children due to domestic
violence. |
| No |
Yes |
There are protective/restraining order in effect or pending as a result of allegations of domestic
violence. |
| No |
Yes |
There currently is, or has been, a Criminal Court Case filed. |
| No |
Yes |
There currently is, or has been, a Children’s Court Case filed. |
| No |
Yes |
Your family has been, or is currently, involved in a Child Custody Evaluation. |
INFORMATION ABOUT THE OTHER PARENT:
Other Parent’s Name:
E-mail:
Cell#:
Home Phone #:
INFORMATION ABOUT THE CHILDREN:
Name(s) and age(s) of any other child(ren) who reside in your home:
WHAT WOULD YOU LIKE TO BE THE PROPOSED CUSTODY AND VISITATION PLAN? (PLEASE INCLUDE ANY CONCERNS
THAT YOU HAVE FOR EXAMPLE SUBSTANCE ABUSE OR ANY OTHER ISSUE THAT YOU THINK MAY AFFECT THE
CUSTODY OR VISITATION OF THE CHILDREN WITH EACH PARENT):
Date (mm/dd/yyyy):
Signature:
Click on View PDF to verify the information on the form and save a copy for your record.
Make sure your browser is not blocking pop-up windows from www.lacourt.org
After You have verified the information on the form and downloaded a copy for your record,
you may click the "Send Mediation Form" button to send the Mediation form to Family Court Services.