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KING COUNTY SUPERIOR COURT

FAMILY COURT SERVICES

REFERENCE QUESTIONNAIRE

Name and Phone Number of parent/guardian for whom you are completing the questionnaire:

             Father/Respondent                                                                               

                    Name                                                             Phone

                                                                                                                               

                    Social Worker                                                Phone

                                                                                          200020842                    

     Superior Court Cause No                           Family Court Services No.

                    IN RE:                                                                                                                                      

INSTRUCTIONS

As you answer each question below, please keep in mind that it is the responsibility of the Court to safeguard the welfare and future development of the child(ren) in this family. You can help the Court in meeting this responsibility by being objective. The evaluator may contact you to discuss your statement with you. This questionnaire is to be completed immediately and returned to: Regional Justice Center, Family Court Services, 401 North Fourth Avenue, Suite 1D, Kent, WA. 98032.

Your Name                                                                        

Your address                                                                     

Street                                                                  City                  Zip

Your phone  _____                    _______

Home                                                                Work

 

Your relationship to the parent/guardian above (friend, relative, mother, father, employer, etc.)____Friend___________

 

How long have you known this parent/guardian?                    15 Years                    

How often do you see him/her:   10 x's year            Date last seen   December 16 2000

 

How long have you known the child(ren) in this case:               Since Birth                     

How often do you see them:      5-6 times year       Date last seen  September 21 2000  

Do you know the other parent?   Yes                      no                    

If yes, for how long:                 4 years                       Date last seen  September 21 2000  

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A) PHYSICAL ENVIRONMENT:

If you have been in the home of the parent/guardian for whom you are a reference, describe

the home including housekeeping standards, who prepares meals, etc.:

The house is clean, and tidy. Both prepare meals for . Dishes are always done, Floor is clean.

 

B) CARE OF CHILD(REN):

Describe how this parent/guardian treats the child(ren) (cleanliness, clothing, discipline, supervision):

Father/Respondent has always been good with . is always clean, and well behaved.  Father/Respondent is looking after with his best interests in mind. Any discipline I have seen is  normal. If did something wrong, the usual discipline that I have observed was a time out. I have never seen the Father/respondent harm . He is very caring towards his son.

 

Describe the quality of the relationship between the parent/guardian and the child(ren):

In my opinion, the Father/Respondent has a good relationship with . When they discovered   could not hear, the father respondent went to sign language classes so he could communicate with his son.  seems happy when he has been at our house with the father/respondent.

                    

Have you ever witnessed physical or emotional abuse of the child(ren) by either parent/guardian (explain and give details):

I have never seen either parent be abusive towards .

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C) CHILD(REN):

Describe each child, his/her behavior and include any physical or emotional problems known to you:

is well behaved, and polite child. He appears to be happy, and care free as a child should be.

 

D) PARENTS:

To your knowledge, does either parent/guardian have problems in any of the following areas:

ABUSE OF ALCOHOL:                                Yes                                          No                   

ABUSE OF DRUGS/NARCOTICS              Yes                                          No                   

CRIMINAL INVOLVMENT:                            Yes                                          No                   

If the answer to any of the above is YES, please give details:

 

E) RESIDENTIAL CARE:

What kind of residential plan do you think would best provide for the child(ren)?

A plan that allows both parents quality time with . Any child deserves the right to have both parents in  his/her life. With being unable to hear, I think it is more important he has the support of both parents.

 

Do you feel that either parent is unfit to have residential time with the child(ren)?__Yes _No

If YES, explain why:

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F) ADDITIONAL COMMENTS:

I have known the father/respondent for 15 years, and have never seen him become physically violent with another  person. He is good with , and loves him very much. Everything the father/respondent does is for benefit. He is continuing with his education so he can provide a better life for his son.

 

         I certify that the above information is true and correct to the best of my knowledge.  I understand that by law, "The evaluator/investigator shall make available to counsel and to any party not represented by counsel . (1) the evaluator/investigator's file; (2) texts of diagnostic reports; (3) names and addresses of persons consulted and (4) investigators and any person whom  (s)he has consulted may be called for cross-examination.

                                      12/16/2000                      

Signature                                                      Date

                                                                                                                        rev. 4/97

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