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Cuestionario de violencia en el hogar

Ha indicado que hay violencia en el hogar en su caso. De conformidad con las Reglas de la Corte de California 5.210 y 5.215, le solicitamos que responda las siguientes preguntas, ya que esto ayuda al mediador con la evaluación de seguridad para su familia. Este formulario es para el uso del mediador y no se presentará en la presentación ante la corte ni será accesible a la otra parte. Todos los campos con asterisco (*) son obligatorios

Case Information

Personal Information



Has there ever been any police involvement and/or arrests related to domestic violence between you and the other parent?
Date Location/ City of Incident Reason for Arrest or Police Involvement Police Report Number Arresting Agency Charges Filed
Charges Filed
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:

Types of Violence

Types of Violence checkboxes

Please check any of the types of violence below which have occurred or the other party has threatened to do:

Has either party threatened or tried to commit suicide?
Are you currently afraid of the other parent for any reason?

Please see the following link for Safety Planning for you and your family:

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: (559) 730-5000 Option 6. 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):

I declare under penalty of perjury, under the laws of the State of California, that I have read the information contained herein and the information provided is true and correct.

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