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Child Custody Recommending Counseling Intake Form

You have been referred to Family Court Services for help developing a parenting or visitation plan for the children in this case. The purpose of this intake form is to collect the necessary information to facilitate an agreement between the parties involved regarding parenting decisions, shared parenting, or visitation with the children.  Additionally, it aims to identify and address any potential safety concerns.  This form is for the recommending counselor's use only and will not be filed in the court case.  Any paperwork you want considered by the court must be filed separately with the Clerk of the Court.

If you need further assistance please contact the Self-Help Center located on the third floor of the courthouse in room 310. 

All fields with an asterisk (*) are required

  • Child Custody Recommending Counseling and Voluntary Mediation Sessions will be held in private, and all written and verbal communication will be deemed “official information” (Evidence Code, §1040). Any information may, however, be disclosed to the court.
  • Superior Court of California, County of Humboldt is a "recommending" county. This means that if the parties are unable to come to an agreement regarding custody and/or visitation the mediator will act as a Child Custody Recommending Counselor and write a report to the court recommending a possible resolution. The Child Custody Recommending Counselor will base this recommendation on the statements of both parties and a background check of any ancillary sources the Recommending Counselor finds necessary to arrive at a recommendation. This is only a recommendation which the Court, the parties and their attorney will be provided prior to a hearing on the issues.
  • Child Custody Recommending Counseling (CCRC) – Court Ordered: The content of the session is not confidential from the Court. If the parties come to an agreement in session, the recommending counselor writes the agreement, the parties sign (if represented by an attorney, the attorney signs), and the judicial officer is provided the report for signature. Once the report becomes a Court Order, a copy of the report is provided to the parties and is filed in the public portion of the Court file.
  • If there is not an agreement between the parties, the counselor prepares a report with recommendations to the Court which is filed in a Confidential section of the Court file and provided to the parties prior to the Court hearing. The report is confidential from everyone but the parties, the judicial officer, and some court staff.
  • In Child Custody Recommending Counseling there are certain situations in which the mediator may reveal information without your permission. They are not required to inform you of their actions in this regard.
  • If you threaten to harm another person, if you threaten to harm yourself, or the mediator/recommending counselor has a reason to suspect child abuse/or neglect, the mediator/recommending counselor may contact the applicable person/protective agencies.

Case information:

Mandatory orientation prior to Child Custody Recommending Counseling:

Have you completed the required 30 minute video entitled: Orientation to Family Court Mediation and Child Custody Recommending Counseling?

Before proceeding open the following link to watch the orientation video:  https://www.humboldt.courts.ca.gov/self-help/child-custody-recommending-counseling/child-custody-recommending-counseling-orientation

The following 2-3 hour Parenting After Separation Online Course is HIGHLY RECOMMENDED to prepare you for your session. This Course also provides a Certificate of Completion at the end and you may file this with the Court, although this is voluntary at this time. https://pas.familieschange.ca.gov/

Is this the first time you have attended CCRC in Humboldt County?
Do you currently have a court order for custody and visitation in Humboldt County?
Do you have a full agreement with the other parent that you would like written up by the court?
Do you currently have a court order for custody and visitation in another county?

Personal information:

Distance between homes and availability of transportation:

Distance between the home of the parties:
I have the following transportation available:

Employment:

Are you presently employed?
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Attorney Information:

Name Phone Number Who do they represent?

Minor children in this case:

First name: Last name: Date of birth: Age: School:

Other people living in your home:

First and last name: Age: Relationship:

Current relationship:

Do you and your current spouse or partner reside in the same home?

History of relationship to other parent in this case:

If not married to the other parent, did you live together?

Well being:

Do the children have any special educational/emotional/health needs that could impact custody and/or visitation?

Safety:

Do you have any safety concerns regarding the children spending parenting time with the other parent?
Please mark the safety areas below:

Domestic Violence:

Is there currently a Protective Order (Restraining Order or Criminal Protective Order) in effect protecting you, your children, the other parent, or the significant other of the other parent?
Are you, under penalty of perjury, alleging that there is a history of domestic violence between you and the other parent?

*THIS IS A REQUIRED FIELD

Domestic Violence Supplemental Questions
Were your children present during the violence?
Were any weapons involved?
Does the other party have access to firearms or weapons?
Was medical attention required?
Within the past year has the frequency:
Has either party threatened or tried to commit suicide?
If so, who?
Are you currently afraid of the other parent?

Please see the following link for Safety Planning for you and your family: https://www.courts.ca.gov/1263.htm

The mediator/ recommending counselor will contact you privately by telephone prior to your session to review your responses and discuss the safest way to proceed with your session. Should your contact information change prior to your mediation session, you must notify Family Court Services immediately at: 707-445-7256 Option 5 or mediation@humboldtcourt.ca.gov. Failure to provide correct contact information may result in delays to your case.

After reading Family Code Section 3044, please answer the following questions:

Family Code Section 3044

Pursuant to Family Code Section 3113 and 3181, are you requesting a separate mediation session due to a history of domestic violence between you and the other parent?
If there is a protective order in place, pursuant to Family Code Section 6303, are you requesting a support person be present during your session?

Criminal history:

Have you ever been arrested, or been in jail or prison?
Date of arrest: County/State in which arrest occurred: Reason for arrest: Arresting agency:
Are you, under penalty of perjury, required to be registered as a sex offender under Section 290 of the Penal Code where the victim was a minor?
Is anyone in your household, or your significant other required to be registered as a sex offender under Section 290 of the Penal Code where the victim was a minor?

Alcohol / Drug Abuse

Do you presently or have you ever abused the following:

Child Abuse

FAMILY CODE §3027: Monetary Sanctions for False Accusations of Child Abuse or Neglect. (a) If a Court determines that an accusation of Child Abuse or Neglect made during a child custody proceeding is FALSE at the time the accusation was made, the Court may impose reasonable monetary sanctions not to exceed ALL COSTS INCURRED BY THE PARTY ACCUSED AS A DIRECT RESULT OF DEFENDING THE ACCUSATION and reasonable attorney fees incurred in recovering sanctions against the person making the accusation. For the purpose of this section, “person” includes “a witness”, a “party” or a “party’s attorney.
 

Is there currently, or has there ever been, a reasonable suspicion of child abuse?
Has Juvenile Court filed a dependency petition for any of the children in this case?
Type of abuse (check all that apply):
Was the incident reported to CPS or police?

Parenting plan and strengths assessment:

What kinds of communication do you have with the other parent regarding the children? (Check all that apply):
Is this communication working?

You will receive a confirmation email from Family Court Services with instructions on how to participate in your session.

Should your contact information change prior to your mediation session, you must notify Family Court Services immediately at: 707-445-7256 Option 5 or mediation@humboldtcourt.ca.gov. Failure to provide correct contact information may result in delays to your case.

Session Attendance Preferences

Do you prefer to attend your session (select all that apply)

 

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