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:

 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:

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:

______________

Yes

(If “yes”, approximate date of completion)

Other Parent’s/Party’s Name: ______________________________________ A Separate Interview is Preferred:

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:

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

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 - - - - - - - - - - - - - - - - -

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

Yes

The children have been physically hurt by either you or the other party.

Yes

The Department of Children and Family Services (DCFS or CPS) is currently, or has been, involved with your children.

Yes

The police or other law enforcement have been involved with you or the children due to domestic violence.

Yes

There are protective/restraining orders in effect or pending as a result of domestic violence.

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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