CCRC/Mediation Intake Packet | Lassen Superior Court

LASSEN SUPERIOR COURT - FAMILY COURT SERVICES

2610 Riverside Drive, Susanville, CA 96130 - (530) 251-8205
CHILD CUSTODY RECOMMENDING COUNSELING (CCRC)/MEDIATION QUESTIONNAIRE

Instructions for Completing Electronic Questionnaire
This form consists of 11 pages, please take your time and fill in all required * fields truthfully and to the best of your knowledge.

Saving Progress & Completing Later

At any point in your completion of this questionnaire, you can save your progress and continue later. To do so, click the button at the bottom of any page. A box will appear asking you to Sign Up or Sign In, if you do not wish to make an account, click Skip Create an Account at the bottom of the box.

Enter your email address and click Send to have a link to continue your form emailed to you. Or, click Get Draft Link to copy the link to return to your saved draft to the clipboard on your device.

This button hidden - used to show agreement separate from instructions

Have there been any instances of domestic violence in your relationship with the other parent?*

NOYES
Yes - Please complete the Declaration of Alleged Domestic Violence on the next page.
Rule 5.210 of the California Rules of Court requires that the Court provide an orientation to inform the parents about the mediation process, the mediator's role, how to address children's developmental needs, limitations on confidentiality, and other child custody issues. The Superior Court in Lassen County complies with this requirement by offering an online orientation http://www.lassencourt.ca.gov/videos/Family-Court-Mediation.mp4 and FCS Information Packet, which can be downloaded from the court’s http://www.lassencourt.ca.gov/court_divisions/family.shtml

You must complete the online orientation before attending CCRC

By signing below, I agree to watch the online orientation before my scheduled CCRC.
STIPULATION TO PLACE MATTER ON FAMILY LAW CALENDAR

Parties are voluntarily attending Child Custody Recommending Counseling (CCRC By signing below, I stipulate that the matter will be placed on the Family Law Calendar for the Court to make appropriate orders on any unresolved issues when parties do not reach a full agreement. I request a court date set two-four weeks after our CCRC session, typically on Wednesday at 1:00 p.m., and a notice of the court date via email or mail. I understand that failure to reach an agreement will result in the mediator's recommendation on unresolved topics.
Signature*

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Date*

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Please click the Next button below to continue.
Please check all that apply:*

I am requesting separate appointmentsI am NOT requesting separate appointments.I am requesting that a support person be present.I am NOT requesting that a support person be present.
I declare under penalty of perjury under California's laws that the preceding is true and correct.
Signature of Declarant*

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Dated*

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LASSEN SUPERIOR COURT, HALL OF JUSTICE, FAMILY COURT SERVICES

2610 Riverside Drive, Susanville, CA 96130 - (530) 251-8205
Case Name
Case No.
I, Full Name* do hereby authorize Lassen Superior Court, Family Court Services to obtain all information about me and/or my minor children, to be used in Child Custody Recommending Counseling/Mediation and/or investigation/evaluation. Court personnel may present this Release of Information to any agency or person, including but not limited to County Welfare Departments, Children’s Protective Services, Probation Departments, County Crisis Centers, County Mental Health Departments, Law Enforcement Agencies, Psychiatrists, Psychologists, Counselors, Educational Institutions or Teachers, Dentists, Medical Personnel, and friends and relatives. This form also authorizes the release of any drug/alcohol test results.

This Release authorizes the Superior Court of Lassen County, Family Court Services, its officers and agents, to exchange any information on myself and my minor children to allow Family Court Services to reasonably recommend on the issues currently before Lassen Superior Court or to make referrals to outside agencies.

Additionally, this information may be referred to or attached to any investigative report or recommendation to the court to clarify the issues. Therefore, the court may release said information to the parties in this action and their attorneys.

I acknowledge that the Superior Court of Lassen County, Family Court Services, and its officers and agents cannot prevent the parties and their attorneys from disclosing the information referred, attached, or contained in an investigative report to unauthorized persons. I release Lassen County Superior Court, Family Court Services, its officers and agents, from any liability therefore.

The court has informed me that I have a right to a copy of this Authorization, and it shall be in effect for a period of one year commencing upon the date of signature.
Signature*

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Date*

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What is said in Child Custody Recommending Counseling is confidential under the law. Persons appearing by telephone or videoconference must follow these rules:

1. Please allow up to four hours to participate in your session.

2. You may not record any part of the conversation, use a speakerphone, allow anyone to be in the room with you, or use a cell phone in public. You may not let anyone listen to any part of your session on an extension phone line.

3. Children are not allowed to participate in the session. The children may not be in the room with you, listening in, or able to hear the conversation under any circumstances. It is harmful to children to see their parents upset, hear damaging information about their other parent, or hear parenting time negotiation.

4. You must ensure that you have supervision for any child aged seven or younger for the duration of

the session. Another responsible adult or a family member/sibling aged 12 or older may supervise the children.

5. A parent attending by telephone or video call must be in an environment that is quiet, private, uninterrupted, and distraction-free location. Please avoid public environments, participation while driving, working, providing childcare, or other tasks.

6. A parent attending CCRC by telephone or video call must have the ability to open a PDF document using Adobe Reader, Google Docs, or another document-reading format on their electronic device during the telephone session.

7. A parent presenting by telephone or video call must sign and return any document(s) received within 30 minutes of receipt of the document(s Parents will digitally sign Agreements reached in CCRC and

8. The court will consider any breaking or disregard of these rules a failure to cooperate with the process, which could result in penalties and delay of resolution of your court case.

9. The Child Custody Recommending Counselor will terminate any conference call or video call session if he or she feels a parent is breaking these rules and will report the reason to the court in a memo. Failure to cooperate with these rules of confidentiality can result in sanctions.

I wish to attend CCRC by telephone or video conference. I have read, and I understand the above rules, and I agree to abide by them.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear

To protect the safety of court customers, Family Court Services (FCS) staff must make reasonable efforts to keep residential addresses, work addresses, telephone numbers, and email addresses confidential, CA Rule of Court 5.215 (g)(3). Therefore, precautions are taken in all cases and on all Family Court Services documents.

In an age of electronic information and communication, most parents use text messages and email to communicate with each other before and after separation. After separation, it is often the primary means of co-parent communication. Sometimes, a parent no longer wants the other parent to know their cell phone number or email address.

Family Court Services wants to honor and protect your privacy; please answer all of the following questions.
1. Does the other parent know your cell phone number?*

YESNO
2. Does the other parent know your email address?*

YESNO
3. Is there a restraining order that protects you from the other parent?*

YESNO
You may permit Family Court Services to communicate with you and the other parent by email and text message. There are risks with these types of communication that include, but are not limited to, the following possibilities:
1. Emails and text messages can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.
2. Email and text senders can easily misaddress an email or text and send the information to an undesired recipient.
3. Backup copies of emails and texts may exist even after the sender or the recipient has deleted their copy.
4. Employers and online services have a right to inspect emails sent through their company systems.
5. Emails and texts can be intercepted, altered, forwarded, or used without authorization or detection.
6. Emails and texts may not be secure, and therefore a third party may breach the confidentiality of such communications.
The court will use reasonable means to protect the security and confidentiality of all communications via text and email. However, it is impossible to guarantee the protection and privacy of communications that occur with these methods, and the court will not be liable for such disclosures.

Upon your written consent, Family Court Services will send text messages and emails to you and the other parent in a group format (the other parent included in all text messages and emails) to schedule CCRC appointments and send CCRC documents. If you authorize this electronic communication, you must adhere to the following guidelines:
1. You must add the other parent to all of your email and text communication with Family Court Services. For email correspondence, you may request blind Ccs for privacy.
2. You must not use text or email communications with Family Court Services to contact the mediator unilaterally (ex parte communication) nor attempt to discuss issues, case details, or make proposals to the other parent. FCS will not respond to these types of communication.
You do not have to consent to communicate via text or email that includes the other parent. You may opt to communicate via phone call or U.S. mail.

I acknowledge that I have read and fully understand this consent form. I recognize that technology is ever-evolving and that electronic communications cannot be fully protected from unauthorized interception.
I DO NOT AUTHORIZE FAMILY COURT SERVICES TO TEXT OR EMAIL ME AND THE OTHER PARENT. FOR SCHEDULING CCRC APPOINTMENTS OR SENDING CCRC DOCUMENTS. I WOULD LIKE FCS TO COMMUNICATE WITH ME BY PHONE FOR SCHEDULING CCRC APPOINTMENTS AND TO USE THE FOLLOWING PHONE NUMBER:. I WILL DELIVER TO OR PICK UP ALL CCRC DOCUMENTS FROM THE COURT CLERK WINDOW AT THE COURTHOUSE.UNDERSTANDING THE RISKS OF ELECTRONIC COMMUNICATION VIA TEXT OR EMAIL, I GIVE MY CONSENT FOR FAMILY COURT SERVICES TO SCHEDULE CCRC AND SEND CCRC DOCUMENTS TO ME AND THE OTHER PARENT IN JOINT TEXT AND EMAIL MESSAGES USING THE FOLLOWING EMAIL AND PHONE NUMBER:
Phone Number*
Email Address*
Cell Phone Number*
Signature*

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Date*

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Before clicking 'Submit', verify all the information you have entered is correct by clicking the 'Preview PDF' button below.

This will display the document with the responses you have included. This PDF document is what will be submitted to Family Court Services.

If you need to make changes, use the 'Back' button to make the necessary corrections. Once complete, you may submit your intake packet to Family Court Services by clicking the 'Submit' button below.
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	First & Last Name	Sex	Age	DOB	School & Grade/Preschool/Care Provider
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	Counselor’s Name	Telephone Number	Length of Treatment	How Often? 1x/wk. 2x/mo.
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	First and Last Name	Sex, M/F	Age	Relationship to You
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	NAME	AGE	RELATIONSHIP TO YOU
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LASSEN SUPERIOR COURT - FAMILY COURT SERVICES

LASSEN SUPERIOR COURT - FAMILY COURT SERVICES

LASSEN SUPERIOR COURT, HALL OF JUSTICE, FAMILY COURT SERVICES