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SUPERIOR COURT OF CALIFORNIA · COUNTY OF FRESNOFAMILY COURT SERVICES

1130 ‘O’ Street Fresno, CA 93721

(559) 457-2100 (option #4)www.fresno.courts.ca.gov/family/family_court_services.php

Family Court Services Tier 2 Intake Form

Tier 2 Appointment:

Date: Time: 1:00 p.m.

Located on the 1st floor of the B.F. Sisk Courthouse, Family Court Services, #102.

Return Court Date:

Date: Time: Department:

Please read this ENTIRE packet very carefully. This document will provide you with important

information about what to expect from yourTier 2 appointment.

You MUST complete this Tier 2 Intake FormPRIOR to your Tier 2 appointment.

For any information that has not changed since your last appointment with FCS, please write"SAME" in each section.

The FCS Tier 2 Intake Form will NOT be shared with the Judicial Officer or the other partieson the case.

For additional information: www.fresno.courts.ca.gov/family/family_court_services.php

email: FresnoFCS@fresno.courts.ca.gov

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Family Court Services Tier 2 Intake Form

Purpose of Tier 2 Session: The purpose of a Tier 2 session is to provide the parties with additional mediation services.

During the mediation portion of the Tier 2 session, the counselor can help parties formulatea parenting plan regarding the following issues: How the children will spend time with each party (regular time and holidays) How the parties will make legal decisions about the children How the children will be transported and exchanged for the visits Participation in programs or services that may beneficial for the family Safety Considerations

Interviewing Children:

Although parents are expected to actively participate in the mediation process, parents are in NO WAY obligated to agree to a parenting plan during mediation.

Another purpose of the Tier 2 session is to provide the Court with additional informationregarding specific areas deemed significant by the Judicial Officer.

• Although you may talk about many different areas during the Tier 2 session, thecounselor will only provide additional information regarding the specific areas identifiedby the Judicial Officer.

The counselor will write and submit a Tier 2 report that may include, but not be limited to, adescription of collateral contacts with law enforcement or Child Protective Services, interviewswith the child/ren, etc.

• The Tier 2 report will not include any recommendations from the counselor.• The Tier 2 report will not provide a summary of the concerns/requests presented by the

parties during the mediation portion of the Tier 2 session.

If the Court has ordered that the child/ren be interviewed as part of the Tier 2 session, pleasemake sure to bring the child/ren to the Tier 2 appointment at FCS.

Because the counselor will typically be meeting with the parents together, this means thatneither parent will be available to wait with the child/ren in the FCS lobby. You will needto bring a NEUTRAL adult to supervise the child/ren in the FCS lobby while you are meetingwith the counselor or you will need to bring a Photo ID to check the child/ren into the B.F. SiskCourthouse Childcare Center (located on the 1st floor, next door to the FCS office).

• If you are using the Courthouse Childcare Center, please check your children into thechildcare center BEFORE your scheduled appointment time.

If ordered by the Court, the counselor will conduct a private interview with the child/ren, theparties will NOT be included when the counselor interviews the child/ren.

If you do not speak English, you must bring your own interpreter to your mediationappointment. Failure to bring your own interpreter may result in cancellation of your Mediationappointment. The interpreter should be a neutral third-party, not directly connected to the case.

Si usted no habla Inglés, usted debe traer su propio intérprete. La falta de traer su propio

intérprete puede resultar en la cancelación de su Mediación de custodia de los hijos.

Interpreters:

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The counselor has access to documents filed with the Court. The counselor has discretion todiscuss documents provided by the parents during the mediation session, for the sole purposeof facilitating an agreement between the parties regarding custody and visitation. Thecounselor will NOT retain any documents presented by the parties during the Tier 2mediation. If you want your documents considered by the Judicial Officer you must file thedocuments with the Court. Please contact the Family Law clerk's office for assistance.

Confidentiality: Pursuant to Family Code §3188, Mediation is private and confidential. Other than reporting the

parties' agreement to the Court, the counselor will not disclose what occurred in themediation portion of the Tier 2 session with the following exceptions:

• If the counselor determines there is reasonable suspicion of danger to one of theparties or others, the counselor is required to report suspected child abuse, elder abuse,and/or if someone is a danger to themselves or others to the appropriate agency.

• In the event of a partial agreement the counselor will report the partial agreement to theCourt. In addition, a list, in neutral terms, of the unresolved issues may be provided tothe Court with consent from all parties.

Documents:

Family Court Services Tier 2 Intake Form

Pursuant to Family Code §3181, where there has been a history of domestic violence betweenthe parties or where a protective order as defined in §6218 is in effect, at the request of theparty alleging domestic violence in a written declaration under penalty of of perjury or protectedby the order, the counselor appointed pursuant to this chapter shall meet with the partiesseparately and at separate times.

If you feel that separate sessions are appropriate due to a history of domestic violence,please contact Family Court Services IMMEDIATELY to complete a "Request forSeparate Sessions". This request should be submitted to Family Court Services at leastfive days prior to your Tier 2 appointment.

Separate Sessions:

If you have NOT completed the Online FCS Orientation with the last 12 months, completion ofthe FCS Orientation is ordered by the Court and is essential to your success in the Tier 2session. The Orientation will provide essential information about your upcoming FCSappointment.

• You can view the complete FCS audio and visual slide show Orientation Online atwww.fresno.courts.ca.gov/ family/family_court_services.php

o The same online slide show will be shown in the FCS lobby every Friday at1:00pm in English and at 2:30pm in Spanish.

Orientation:

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Case Number: SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO

FAMILY COURT SERVICES TIER 2 INTAKE FORM PERSONAL INFORMATION

Name: Other Names Used:

(First) (Middle) (Last) (Nickname, Aliases, Maiden Name)

City:

(Number and Street Name) (Apartment No.)

Zip: County:

Address:

State:

Phone Number(s): ( ) ( ) Date of Birth: (Home) (Work / Cell)

OTHER PARENT / PARTY’S PERSONAL INFORMATION

Other Parent’s / Party’s Name: Date of Birth:

(First) (Middle) (Last)

EMPLOYMENT

Employer (if unemployed, Please Write “Unemployed”):

Work Schedule: MON TUES WED THURS FRI SAT SUN Work Hrs:

ATTORNEY

Name: Phone Number:

MINOR CHILDREN IN THIS CASE

Name DOB School Name DOB School

OTHER ADULTS IN YOUR HOME

Name DOB Relationship Name DOB Relationship

DOMESTIC VIOLENCE

Yes No

Yes No

1. Is there currently a Restraining Order in effect protecting you or the other parent?

Expiration date:

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

3. If you answered YES to question #2: Were the child/ren present during the violence? Yes No

4. Are you requesting a separate mediation session due to a history of domestic violence

between you and the other parent? Yes No

If YES to #4, would you like for the FCS staff to provide you with information about creating a Safety Plan: Yes No

If you answered ‘YES’ to questions #2 and #4, please immediately contact Family Court Services or go to the FCS website to receive a packet regarding your request for separate mediation sessions.

No

Yes No

Was medical attention required?

Was Law Enforcement involved?

Were any weapons involved?

No Yes

Yes

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QUESTIONNAIRE

1. Do you currently have a Court order for custody and visitation: Yes No

Describe how much time each parent has with the child/rensince your separation:

2. Please provide 2 detailed visitation options, including specific days and times for exchanges:

Visitation schedule 1: Sole Legal Sole Physical Joint Legal Joint Physical

Thanksgiving: Christmas:

Holiday Schedule:

Easter:

Visitation schedule 2: Sole Legal Sole Physical Joint Legal Joint Physical

Holiday Schedule:

Easter: Thanksgiving: Christmas:

3. Approximately, now many miles to you reside from the other parent?

4. Major areas of concern that would justify limited contact between the child/ren and the other parent:

Substance abuse

Child/ren’s resistance to visitation

Neglect of medical care

Use of inappropriate discipline

Exposure to criminal behavior/Arrest History

Child/ren’s poor academic performance

History of child abuse / CPS / Police involvement

Unavailability of other parent to care for the child/ren

Briefly summarize the concerns you have regarding the custody and/or welfare of the child/ren:

Do the child/ren have any special needs that could impact custody/visitation?

SIGNATURE

I declare that the foregoing information, as provided in this entire form, is true and correct.

(Date) (Signature)