6a. Has/have the child/children involved with this custody case been the subject of an indicated or founded report of child abuse? YES NO

6b. Has a party or a member of a party's household been identified as the perpetrator in an indicated or founded report of child abuse? YES NO

6c. If you answered YES to question 6a and/or 6b, please complete the following:

Name of perpetrator: ___

Date(s) of incidents of child abuse: ___

Circumstances of child abuse incident(s):

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County and state where child abuse investigation took place: _____

7a. Has a party or a member of a party's household been provided services by children & youth services, child protective services, or general protective services? YES NO

7b. If you answered YES to question 7a, please complete the following:

Name of agency that provided services: ___

Type of services provided: ___

The circumstances surrounding the provision of services:

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The status of services: ___

Date(s) services provided: ___

County and State where the services were provided: ___