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.

I have read the above explained limits on confidentiality.

Case information:

Case number:

Next court date:

Session date (if known):

Which parent filed the current court action?

What is the action regarding?

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?

Yes

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/

If yes, when?

Is this the first time you have attended CCRC in Humboldt County?

Yes

Do you currently have a court order for custody and visitation in Humboldt County?

Yes

Please describe your current order:

Do you have a full agreement with the other parent that you would like written up by the court?

Yes

Briefly describe the parenting schedule you would like to have:

Do you currently have a court order for custody and visitation in another county?

Yes

Enter county:

What is the date of your current court order:

Personal information:

First

Middle

Last

Other names used:

Date of birth:

Email:

Address

City/Town

ZIP/Postal Code

County:

Contact phone number:

Distance between homes and availability of transportation:

Distance between the home of the parties:

0-10 Miles

10-30 Miles

30-60 Miles

Over 60 Miles

What location is the midway point between the two homes?

I have the following transportation available:

Private Vehicle

Public Transportation

Unknown

Other…

Employment:

Are you presently employed?

Yes

Employer:

Daily Work Schedule:

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

Variable work schedule:

Variable hours:

Attorney Information:

Enter you or your children's attorney(s) if applicable:

Name	Phone Number	Email	Who do they represent?
Name	Phone Number	Email	Who do they represent?

Minor children in this case:

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

Other people living in your home:

First and last name:	Age:	Relationship:
First and last name:	Age:	Relationship:

Current relationship:

Name of CURRENT spouse or partner:

Date of birth:

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

Yes

History of relationship to other parent in this case:

Date of marriage or date you began your relationship:

Date of separation:

Date of dissolution/divorce:

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

Yes

How long did you live together?

Well being:

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

Yes

Briefly describe:

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?

Yes

Expiration date:

List the protected parties:

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

Yes

*THIS IS A REQUIRED FIELD

Domestic Violence Supplemental Questions

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?

Yes

Date of last incident:

I agree to waive this right.

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?

Yes

I agree to waive this right.

First & last name:

Relationship:

Criminal history:

Have you ever been arrested, or been in jail or prison?

Yes

Date of arrest:	County/State in which arrest occurred:	Reason for arrest:	Arresting agency:
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?

Yes

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?

Yes

Alcohol / Drug Abuse

Do you presently or have you ever abused the following:

Illegal drugs

Prescription drugs

Alcohol

Marijuana

Other

None

If any other than 'none' apply, list drug(s) of choice:

Judicial Branch of California

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Website Feedback Survey:

Child Custody Recommending Counseling Intake Form

Case information:

Mandatory orientation prior to Child Custody Recommending Counseling:

Personal information:

Distance between homes and availability of transportation:

Employment:

Attorney Information:

Minor children in this case:

Other people living in your home:

Current relationship:

History of relationship to other parent in this case:

Well being:

Safety:

Domestic Violence:

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

Criminal history:

Alcohol / Drug Abuse

Child Abuse

Parenting plan and strengths assessment:

Session Attendance Preferences

Was this helpful?

Request

Website Feedback Survey:

Child Custody Recommending Counseling Intake Form

Limits on Confidentiality of the Child Custody Recommending Counseling

Case information:

Mandatory orientation prior to Child Custody Recommending Counseling:

Personal information:

Distance between homes and availability of transportation:

Employment:

Attorney Information:

Minor children in this case:

Other people living in your home:

Current relationship:

History of relationship to other parent in this case:

Well being:

Safety:

Domestic Violence:

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

Criminal history:

Alcohol / Drug Abuse

Child Abuse

Parenting plan and strengths assessment:

Session Attendance Preferences