Form Fam 012 PDF Details

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QuestionAnswer
Form NameForm Fam 012
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfam 012 form, http, fam 012 download, california fam 012

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Superior Court of California, County of Los Angeles

FAMILY COURT SERVICES

Mediation Intake Form

This form must be completed by all parties and be submitted to Family Court Services (FCS) at FCSParentInfo@LACourt.org prior to the Child Custody/Visitation Mediation. Please type or print clearly. All files and records in FCS are confidential, except when a mandated report is necessary (e.g. suspected child abuse or threats to harm yourself or others).

Party completing the forms is the: ☐Petitioner ☐Respondent Interpreter Needed: ☐Yes ___________(Language) ☐No

Case Number: ___________________ Next Hearing Date: ______________________ in Dept. __________________

Name: __________________________________________Date of Birth: ___________ Cell/Home Phone#: _____________

First Middle Initial Last

Address: _______________________________________________________________ E-mail: _______________________

Number Street (Apt.) CityState Zip

Occupation: ____________________________________________________________ Work Phone#: __________________

Type of EmploymentEmployerWork Hours

Attorney: ____________________________________________________________________________________________

NameAddress (Number, Street, Suite, City, State, Zip)Phone Number

Other Parent’s/Party Name: _________________________________________

Cell#: ___________________ Home Phone #: _______________________ E-mail: ___________________________

The online orientation, OUR CHILDREN FIRST, was completed: ☐No ☐Yes

Do you request A SEPARATE INTERVIEW? ☐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).

Mediation is regarding the following Child(ren):

Name

Date of

Birth

Age

Grade Level of Child

Parent/Party with whom

child mostly resides

Name(s) and age(s) of any other child(ren) who reside in your home:

LASC FAM 012 Rev. 7/20

Page 1 of 2

For Mandatory Use

Name: ____________________________________________________ Case Number: _____________________________

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

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.

Describe the frequency of your contact with your children.

What are you most interested in resolving today? Include concerns (e.g. substance abuse, etc.) that may affect a custody/ visitation plan.

Date: ___________________

Signature: ___________________________________

Attention: Please check the Family Law page of the Los Angeles Superior Court website for translation in Spanish, Korean, Vietnamese, Armenian, or

Chinese language.

LASC FAM 012 Rev. 7/20

Page 2 of 2

For Mandatory Use

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3. Completing Name Case Number, PLEASE REVIEW EACH STATEMENT, No Yes, One or more of the following has, shoving grabbing forced sex, Violence describe, The violence occurred Less than, The children have been physically, No Yes No Yes, No Yes, No Yes, No Yes No Yes No Yes, and Describe the frequency of your is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

How to fill in lacourt org fam012 part 3

4. This next section requires some additional information. Ensure you complete all the necessary fields - What are you most interested in, Date, Signature, Attention Please check the Family, LASC FAM Rev For Mandatory Use, Chinese language, and Page of - to proceed further in your process!

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