Superior Court of California, County of Los Angeles

PARENT QUESTIONNAIRE FOR PARENTING PLAN ASSESSMENT/ CHILD INTERVIEW

INSTRUCTIONS: the questionnaire is important for introducing you and your family to the FCS specialist assigned to conduct your Parenting Plan Assessment. The purpose of this assessment is to develop and recommend a parenting plan in the best interest of your children.

Please consult the PPA brochure for further information. If you have any questions, please contact 213-830-0835.

Name: Date of Birth (mm/dd/yyyy):
Other name you are known by/Maiden name:
Address:
Home Number: CellPhone Number: Work Number:
Drivers/ID Number:
Address:
Full address includes Number, Street, (Apt.), City, State, and Zip.
Email Address:
Occupation:

Do you require an interpreter? Yes No If so, What language?
Attorney:

CHILDREN: List the Child/Children involved in this court action:

Name	Date of Birth (mm/dd/yyyy)	Age	Grade Level of Child	Name of School Address/Telephone Number

List the names and birthdates of other children in the home:



List the full names and birthdates of all other adults living in your home:


List each child in this case who has been receiving treatment from counselor, therapist or psychiatrist:

CHILD	DOCTOR/COUNSELOR	ADDRESS / TELEPHONE NUMBER	DATE

COUNSELING AND SUBSTANCE ABUSE TREATMENT HISTORY FOR PARENTS:

MOTHER	FATHER	COUNSELOR	ADDRESS / TELEPHONE NUMBER	DATE

CRIMINAL HISTORY

Has either parent been arrested?     Mother: Yes   No      Father: Yes   No 

Dates of arrest(s):


Please review each statement below and check the boxes that apply:

Yes	No	One or more of the following has occurred in your relationship with the other parent: slapping, punching, choking/ strangulation, kicking, shoving, grabbing, forced sex, threats of (describe), or other violence . ﹍ The violence occurred: Less than one year ago More than one year ago ﹍ The violence occurred: Once between the parties More than once between the parties
Yes	No	The children have been physically hurt by either you or the other party.
Yes	No	The police have been involved with you or the children due to domestic violence.
Yes	No	There are protective/restraining orders in effect or pending as a result of domestic violence.
Yes	No	The Department of Children and Family services (DCFS) is currently, or has been, involved with children.
Yes	No	There currently is, or has been, a Criminal or Children’s (Dependency) Court case filed.

PRESENT PARENTING PLAN: When are the children with you and when are they with their other parent?

PROPOSED PARENTING PLAN: Please describe the schedule for the parenting plan that you are requesting and include all options that you will consider.

REASONS FOR YOUR REQUEST: Please explain why you are requesting this parenting plan and include any concerns you have about your children or their relationship with their other parent.


Click on View PDF to verify the information on the form and save a copy for your record.