Petition For Conciliation - Superior Court Of California, County Of Los Angeles

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Superior Court of California, County of Los Angeles
For Court Use Only:
For Court Use Only:
 Separate Sessions
Date: ___/___/___ at ___
PETITION FOR CONCILIATION—FC § 1833
Requested
 Appointment
 DVPA Filing
By law, this petition, all files and records in Family Court Services are confidential,
 Walk-In from Dept. ____
(Or other DV
*except when a mandated reporting situation (e.g. suspected child abuse) exists.
Matter)
Mediator:
This *confidential (see above exception*) Family Court Services (FCS) form must be completed by all parties, and
be submitted to FCS prior to, or at the time of the Child Custody/Visitation Mediation. Please print clearly.
Party completing the form is the:
Petitioner
Respondent
Interpreter needed:
No
Yes _________________________(language)
Matter is:
Predissolution
Postdissolution
Paternity (never married)
Domestic Violence
Child Support
Guardianship/Probate
Case #: ________________________ BG#: ________________________ Next Hearing/Trial Date: _________________ in Dept. _____________
Name: ___________________________________________ Date of Birth: __________ Day/Work Phone #: ___________________
First
Middle Initial
Last
Address: __________________________________________________________________ Home Phone #: ___________________
Number
Street
(Apt#)
City
State
Zip
Occupation: _________________________________________________________________________________________________
Type of Employment
Employer
Work Hours
Days Off
Attorney: ___________________________________________________________________________________________________
Name
Address (Number, Street, Suite, City, State, Zip)
Phone Number
OUR CHILDREN FIRST or the PACT (Parent And Children Together) program was completed:
______________
No
Yes
(If “yes”, approximate date of completion)
Other Parent’s/Party’s Name: ______________________________________ A Separate Interview is Preferred:
No
Yes
 If a history of domestic violence and/or a Protective/Restraining Order exists, clients will be interviewed separately (unless otherwise indicated by mediator)
There currently is, or has been, a Criminal or Children’s (Dependency) Court case filed:
No
Yes
(If “yes”, please circle type of court)
Mediation is in regards to the following child(ren):
Name
Date of Birth
Age
Grade Level of Child
Parent/Party with whom child resides
1.
2.
3.
4.
Name(s) and age(s) of any other child(ren) who reside in your home:
- - - - - - - - - - - - - - - - - - - - - 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 hurt 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 orders in effect or pending as a result of domestic violence.
No
Yes
Your family has been, or is currently, involved in a Child Custody Evaluation.
-Your proposed custody/visitation plan—include concerns (e.g. substance abuse, etc.) that may affect custody/visitation:
-There are existing custody/visitation orders:  No
 Yes
A controversy exists between the parents/parties and the aid of the court is requested to reach an amicable settlement in the best interest of the child(ren).
Dated: _______________, at (City) _________________________, California.
Signature: _________________________________________________
FAM 012 (12/12)
*FAM012*
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