Free Family Court Services Referral Form - California

COURT USE ONLY

SUPERIOR COURT OF CALIFORNIA COUNTY OF FRESNO 2220 Tulare Street, Suite 1111 Fresno, CA. 93721 Phone: (559) 488-3241 Fax: (559) 262-4362

FAMILY COURT SERVICES REFERRAL FORM FL / FS Case Number: FCS Case Number: Case Name: Previous Mediation with Family Court Services? Yes No Current Domestic Violence or Restraining Order in place at this time? Interpreter Needed? Yes No Filing Party: Petitioner Petitioner: Home Address: City: Personal Service: Respondent: Home Address: City: Personal Service: Claimant: Home Address: City: Personal Service: Respondent Claimant Yes Language: No

State: Zip: Attorney:

Phone: (H)

(W)

State: Zip: Attorney:

Phone: (H)

(W)

State: Zip: Attorney:

Phone: (H)

(W)

Children of this Relationship: Child's Name

Children 5 years old and older Age Date of Birth

(number):

Lives with

FOR INTERNAL OFFICE USE ONLY Orientation Date: Mediation Date: Court Date: Previous Counselor: Current Counselor: Time: Time: Time: Department: Date Mailed:

TFC-43 R06-05