MODOC SUPERIOR COURT - FAMILY COURT SERVICES
CHILD CUSTODY RECOMMENDING COUNSELING (CCRC)/MEDIATION QUESTIONNAIRE
Court Case #
Next Scheduled Court Date
-
Month
-
Day
Year
Date
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Former or Other Names
If applicable
Email Address
*
Confirmation Email
example@example.com
Does the other parent know your cell phone number?
*
Yes
No
When scheduling and sending documents, Family Court Services may send text messages and emails that include the other parent. Is there a reason you don’t want the other parent to know your cell phone number or email address?
*
Yes
No
The following information is confidential and is used to facilitate your CCRC/Mediation. The information provided is for Court personnel only.
General Information
Mailing Address
*
Street, Apt/Unit, City, St Zip
Physical Address
*
Street, Apt/Unit, City, St Zip
How long have you lived at this address?
*
Years/Months
Best phone number to reach you
*
Years/Months
Best phone number to reach you
Please enter a valid phone number.
Format: (000) 000-0000.
Employment
Are you currently employed?
*
Yes
No
Other Parent
Other Parent's Name
First Name
Last Name
Former or Other Names
Other Parent's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Other Parent's Mailing Address
If known - Street, Apt/Unit, City, St Zip
Attorney Representation
Are you represented by an attorney?
Yes
No
Does the other parent have an attorney?
Yes
No
CCRC
Have you been to CCRC/Mediation before?
Yes
No
If "Yes," what county and date?
If you're not sure of exact date - estimate
What do you want to address or hope to accomplish in CCRC/Mediation?
Submit
Should be Empty: