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Judicial Branch of California

Formulario de admisión de los padres para la mediación de custodia de los hijos

El propósito de la mediación es desarrollar un plan que garantice que los menores tengan una buena relación y mucho tiempo con cada padre.

Introducción a la mediación

Servicios de la corte de familia del condado de Lake.

Esta información CONFIDENCIAL es solo para la oficina de mediación y no será entregada al otro padre.

Pautas para la mediación:

Trate a todas las personas y temas con respeto.
Toda persona tiene el derecho de hablar y de ser escuchada.
Sea lo más sincero(a) posible.

Pasos:

El mediador pide a cada persona que hable de la situación y se dirija directamente al mediador en un primer momento.
El mediador invita a los padres a hablar directamente entre ellos.
Se pide a los padres que escuchen atentamente y sean capaces de repetir lo que escucharon decir a la otra persona.
Los padres ofrecen ideas para elaborar un plan que funcione para los menores y para cada padre.
Los padres eligen las ideas con las que están de acuerdo.

Confidencialidad - Todo lo que se discuta en la mediación es confidencial. Esto significa:

No se da ninguna información de la mediación a la corte.
No se permite ningún tipo de grabación.
Ninguna otra persona puede estar presente o ser capaz de escuchar la conversación.
No hay comunicación con la otra parte ni con nadie mientras mantenemos la conversación.

Excepciones:

El mediador está obligado a denunciar los maltratos a menores o las amenazas de violencia.

Formulario de admisión de los padres para la mediación

I understand and accept the above guidelines. I also understand and agree to comply with the confidentiality requirement.

Mediation Intake Webform

Today's Date

Next Court Date

Your Case Number

Personal Information

Name

First

Last

I am a

Petitioner

Respondent

Date of Birth

Other Last Names used

Phone #

Email Address

Address

City/Town

ZIP/Postal Code

Work Information

Employer

Occupation

Work Schedule

Family Information

Members of the Family

Names of other Adults in your Home	Relationship to you
Names of other Adults in your Home	Relationship to you

Have you been in mediation regarding care of your child(ren) before? Where (County)

When?

Do you have an attorney? Name of the Attorney (if applicable)

Name of the Attorney	Phone number
Name of the Attorney	Phone number

First

Middle

Last

Last time you lived with them:

Other Information

Who are the children (under 18) this mediation will be about?

First and Last Name	Age	Date of Birth	Sex	School	Time with each Parent
First and Last Name	Age	Date of Birth	Sex	School	Time with each Parent

SPECIAL NEEDS OF CHILDREN: medical/dental, educational, counseling

When was the last time you saw your child(ren)?

Other children in your home for any length of time:

Name	Age
Name	Age

Do you plan to move in the next six months?

Yes

No

If so, when and where?

Do you have another case in Family Court Services?

Yes

No

If yes, name of the other parent /County

Have you ever feared you would not be able to see your children?

Yes

No

Do you have any concerns regarding the use of alcohol and/or drugs by family members?

Yes

No

Have there ever been any physical confrontations between you and the other parent?

Yes

No

If yes, give the date of most recent physical confrontation. Please describe the physical confrontation.

Were the children present or able to see or to hear it?

Yes

No

Have there ever been threats of the use of weapons against either of you parents or your children?

Yes

No

If yes, describe the incident including the names of the people involved.

Have you ever asked for a restraining order against the other parent?

Yes

No

If yes, in what state and county?

Has the other parent ever been abusive to any other family member?

Yes

No

Has the other parent ever been abusive to a family pet or other animal?

Yes

No

Has there ever been a criminal domestic violence case against the other parent?

Yes

No

If so, in what state and county:

Do you have any concerns about your own physical safety?

Yes

No

Do you believe that you are considered an equal partner with the other parent?

Yes

No

Has any adult ever used physical punishment on your child?

Yes

No

If so, who punished the child ?

When did this occur? Please describe the incident(s).

Has Child Welfare Services investigated abuse of any of your children?

Yes

No

For which children? Please describe.

Have you ever been arrested as an adult?

Yes

No

If yes, answer the following:

What State	County	What Charges?
What State	County	What Charges?

Are there any criminal actions pending against you or any adult in frequent contact with the child(ren)?

Yes

No

If yes, answer the following

Name of the Adult	What State	County	What Charges?
Name of the Adult	What State	County	What Charges?

Do you have a current PROTECTIVE ORDER of any kind?

Yes

No

RIGHT TO SEPARATE SESSIONS: If a party alleges domestic violence in a written declaration under penalty of perjury, or a party protected by a protective order so requests, Family Court Services staff must meet with the parties separately at separate times. DO YOU WISH TO BE SEEN SEPARATELY?

Yes

No

RIGHT TO A SUPPORT PERSON: If the court has issued a PROTECTIVE ORDER, a support person shall be permitted to accompany protected party during any mediation orientation or mediation session, including separate mediation sessions. It is the function of a support person to provide moral and emotional support. The support person is not present as a legal adviser and shall not give legal advice. DO YOU WISH TO HAVE A SUPPORT PERSON ACCOMPANY YOU IN MEDIATION?

Yes

No

Signature

I declare that the information on this form is true and correct and that this declaration is executed on the date listed below

Name

Date

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