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
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
YES □
NO □
6c. If you answered YES to question 6a and/or 6b, please complete the following:
Name of perpetrator: ___
6c. If you answered YES to question 6a and/or 6b, please complete the following:
Date(s) of incidents of child abuse: ___
Date(s) of incidents of child abuse: ___________________________________________________
Circumstances of child abuse incident(s):
Circumstances of child abuse incident(s):
County and state where child abuse investigation took place: _____
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
YES □
NO □
7b. If you answered YES to question 7a, please complete the following:
Name of agency that provided services: ___
Name of agency that provided services:
Type of services provided:
rvices provided: ___
Type of services provided:
The circumstances surrounding the provision of services:
The status of services: ___
The status of services: _______________________________________________________________
Date(s) services provided: ___
Date(s) services provided:
County and State where the services were provided: ___
County and State where the services were provided: _______________________________________