The California Family Court Services intake form is the sworn questionnaire each parent completes before a court-ordered custody mediation, giving the assigned mediator your household details, work schedule, proposed parenting plan, and any safety concerns before you meet. Fill it out carefully: the mediator reads it before your session, and in counties where mediators make recommendations to the judge, what you write there can shape the outcome of your case.
Under California Family Code Section 3170, when custody or visitation is disputed the court must send those issues to mediation before a judge rules.1Justia Law. California Family Code Sections 3170-3173 The intake form is how that process starts.
Why the Form Matters More in Some Counties
Every California superior court runs a Family Court Services program, but counties use one of two models. In recommending counties such as San Bernardino, Riverside, and San Diego, the mediator writes a report with custody and visitation recommendations the judge can read before ruling. In non-recommending counties like Los Angeles and Orange, the mediator either drafts an agreement both parents sign or tells the court only that no agreement was reached.2Judicial Branch of California. Guidelines for Child Custody Recommending Counseling
In a recommending county, everything you write on the intake form may directly influence the mediator’s report. In a non-recommending county, the form still frames the mediator’s first impression of your family and your proposed plan.
What to Gather Before You Start
The form asks for specific details most people don’t have memorized. Pull these together first:
- Full legal names, dates of birth, addresses, phone numbers, email addresses, and work schedules (days and hours) for both parents.
- Attorney name and phone number for either parent who has one.
- Each child’s full name, date of birth, and current school.
- Name, date of birth, and relationship for every other adult living in your household — a new partner, a grandparent, a roommate.
- Case numbers and terms of any existing custody, visitation, or restraining orders, including expiration dates.
- Two detailed parenting schedule proposals, with specific days, times, exchange locations, and a holiday rotation covering at least Thanksgiving, Christmas, and Easter or spring break.
If a child has medical needs, behavioral health concerns, or special education services, have the provider names ready. The form asks whether any child has special needs that could affect the arrangement, and the mediator uses those details when weighing whether a proposed schedule works for the child.3Justia. Family Court Services Tier 1 Intake Form
Some counties also require an online orientation before your appointment covering co-parenting, children’s emotional needs, and how to use the session well.4Superior Court of California. Online Orientation Check your county’s court website to confirm whether orientation is mandatory.
Completing the Form Section by Section
Intake forms vary slightly by county but follow the same general structure required by California Rules of Court, Rule 5.210, which mandates a detailed intake process that screens for restraining orders and safety issues before mediation begins.5Judicial Branch of California. California Rules of Court 2026 – Rule 5.210
Personal and Household Information
Fill in your full legal name, any other names you have used (maiden name, nicknames, aliases), your address, phone numbers, email, and date of birth. A separate block covers the same basics for the other parent. The employer and work-schedule fields matter more than they look: the mediator uses your hours to gauge which custody arrangements are physically possible for each parent.
The “other adults in your home” section is for anyone besides yourself living in the household — new partners, extended family, or anyone else who would regularly be around the children. Leaving it blank when someone does live with you creates a credibility problem if the other parent raises it during the session. If no one else lives there, write “none” rather than leaving the field empty.
Children and Current Arrangements
List every child covered by the case, their dates of birth, and their schools. The form then asks whether a court order for custody and visitation is already in place. If one exists, describe the existing schedule. If you have been operating on an informal arrangement since the separation, describe how time has actually been divided.3Justia. Family Court Services Tier 1 Intake Form
Proposed Parenting Plans
Most intake forms ask for two schedule proposals, not one. Each includes checkboxes for the type of custody you want (sole legal, joint legal, sole physical, or joint physical) plus specific days and times for regular parenting time, exchanges, and holidays. The form also asks the approximate distance between the parents’ homes, which affects how practical a proposed schedule is.
Be specific. “Every other weekend” is a starting point, but the mediator needs actual days and times: “Friday at 5:00 p.m. through Sunday at 6:00 p.m.” Vague proposals slow the session because the mediator has to pin down details that should already be on paper. Build in a holiday rotation that addresses major holidays, school breaks, and each parent’s birthday if that matters to you.
Concerns About the Other Parent
The form includes a checklist of concerns that would justify limiting the other parent’s contact with the children. Typical items are substance abuse, criminal behavior or arrest history, a child’s resistance to visitation, neglect of medical care, child abuse or CPS involvement, and inappropriate discipline.3Justia. Family Court Services Tier 1 Intake Form Check only what you can support with facts — police reports, CPS records, medical documentation, or court records. A narrative box below the checklist lets you summarize those concerns in your own words.
The mediator is assessing the best interest of the child under California Family Code Section 3011, which looks at the child’s health, safety, and welfare; any history of abuse; the nature and amount of contact with both parents; and habitual substance abuse by either parent.6California Legislative Information. California Family Code Section 3011 Frame everything you write around how the issue affects the child, not how you feel about the other parent.
Domestic Violence and Safety Sections
The domestic violence portion of the form is not optional, and it triggers procedural protections. You will be asked whether a restraining order is currently in effect, whether you are alleging a history of domestic violence under penalty of perjury, and whether you want a separate mediation session.
Under California Family Code Section 3181, if you have a protective order or allege domestic violence in a written declaration under penalty of perjury, the mediator must meet with each parent separately and at different times if you request it.7California Legislative Information. California Family Code FAM 3181 The intake form itself is required to inform you of this right.8California Courts. Custody Mediation in Cases With Domestic Violence Check the box on the form; don’t wait until you arrive at the appointment to ask.
The form also asks whether children were present during any incident, whether medical attention was required, whether weapons were involved, and whether law enforcement responded. Answer these questions directly, and note any police reports or CPS investigations. Some courts offer to help you build a safety plan, and the form may include a checkbox to request that.
Keeping Your Address Confidential
If sharing your address would put you or your children at risk, the intake form includes a section to request that your address not be disclosed to the other parent. Participants in California’s Safe at Home address confidentiality program use a substitute mailing address on court filings; if you are enrolled, note that on the form and provide the substitute address rather than your physical location.
Signing Under Penalty of Perjury
The intake form ends with a declaration, signed under penalty of perjury, that what you have written is true and correct.3Justia. Family Court Services Tier 1 Intake Form That is a real legal obligation. Exaggerating allegations, hiding a household member, or misstating your work schedule can bring sanctions if a judge discovers it, and it destroys your credibility on every other claim you have made. In recommending counties, an inconsistency between your form and what you say in session goes into the record.
Fill out every field. Rule 5.210 requires the mediator to review the intake form before mediation begins, so an incomplete form can delay your appointment. If you genuinely don’t know an answer — the other parent’s current employer, say — write “unknown” rather than guessing.
Filing the Form and What Happens Next
How and when you submit the form depends on your county. Some courts want it brought to the mediation appointment. Others expect it filed through the family law clerk’s office in advance, in person at the filing window, by mail, or through the court’s electronic filing portal. Check your county court’s FCS page for its instructions.
Court-connected FCS mediation is generally provided at no charge. Contra Costa County, for example, offers mediation appointments free in all pending cases.9Superior Court of California. Family Court Services Electronic filing typically carries a per-transaction fee from the e-filing service provider; Santa Barbara County adds a $5.00 per-envelope e-filing fee on top of the provider’s charge.10Superior Court of California. County of Santa Barbara – E-Filing In-person and mail submissions avoid those convenience fees. If you cannot afford court-related fees, you can request a waiver using Judicial Council form FW-001; receipt of public benefits such as Medi-Cal, CalFresh, SSI, or CalWORKs qualifies you automatically.11Judicial Council of California. Information Sheet on Waiver of Superior Court Fees
Once the court has your paperwork, Family Court Services contacts both parents to schedule the mediation. In Contra Costa County, appointments are scheduled at least two weeks before the hearing on disputed custody issues whenever possible.9Superior Court of California. Family Court Services The assigned mediator reviews both parents’ questionnaires before the session and has a duty to assess the child’s needs and interests, including interviewing the child if the mediator considers it appropriate.12California Legislative Information. California Family Code Section 3180
Raising International Travel Concerns on the Form
If international travel is a concern in your case, put it in the narrative section. Passport applications for children under 16 require both parents to appear in person or provide written consent through a notarized Statement of Consent (Form DS-3053); a parent with sole legal custody can apply alone by presenting a court order granting sole custody or giving that parent alone permission to apply.13U.S. Department of State. Apply for a Child’s Passport Under 16
If you’re worried the other parent might take the children out of the country, raise it explicitly on the intake form and during the session. A parenting plan can include provisions restricting international travel, requiring surrender of a child’s passport, or requiring notarized consent for any trip abroad. Those provisions only bind anyone once they appear in the final court order, so getting them on the mediator’s radar through the intake form is the first step.