2. How did you hear about us? If referred by someone, please list their name. *
您的回答
3. Relationship Status *
4. If Engaged, Married, Separated, or Divorced, please give status and dates of these events: *
您的回答
5. Are you remarried? *
If yes, please list the date of marriage and length of relationship:
您的回答
6. Number of Children: If none, please put "0" in box and skip to question 18. *
您的回答
7. List Children's Name, Age, DOB, and our relationship to the child:
您的回答
Name of other Parent:
您的回答
8. List School(s) each child is attending, grade level(s), and note academic or behavioral problems, if any:
您的回答
9. Living Arrangements: Who is living in the home?
您的回答
10. Does your child/children live in more than one home?
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If yes, please explain where and with whom they are living with:
您的回答
11. Do you have concerns about your child/children's emotional well-being and/or physical safety with the other parent?
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If yes, please explain:
您的回答
12. Has your family ever had any instances or allegations of abuse and/or neglect?
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If yes, please explain:
您的回答
13. Has an Attorney/Guardian ad Litem been appointed to represent the Children?
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If yes, please give name:
您的回答
14. Have you ever feared that you would not have access to your children?
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If yes, please explain:
您的回答
15. Has the other parent ever damaged or destroyed your or your child/children's property or harmed/threatened to harm you or your child/children's pets?
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If yes, please explain:
您的回答
If no, how could these arrangements be improved?
您的回答
17. If you are not happy with your current parenting plan, do you feel you are ready to begin working with the other parent on this?
您的回答
18. Is there a Protective Order in place? *
If yes, what was the expiration date?
您的回答
19. If there are non presently, have there been previous orders of protection? *
If yes, what was the expiration date?
您的回答
20. Has there ever been a physical confrontation? *
If yes, please describe frequency and occurrence:
您的回答
21. Do you have any concerns about your own emotional and/or physical safety with your spouse/partner? *
If yes, please explain:
您的回答
22. Are you in any way intimidated by or fearful of your partner/spouse? *
If yes, please explain:
您的回答
23. Has your spouse/ other parent ever prevented you from having contact with family, friends, or with your children? *
If yes, please give details:
您的回答
24. Do you have concerns regarding the use of alcohol and/or drugs in the family? *
If yes, please list concerns:
您的回答
25. Do you have any fear about answering these questions? *
If yes, please explain:
您的回答
26. Have you or any member of your family recently experienced a traumatic event? *
If yes, please explain:
您的回答
27. Do you feel you were/are an equal partner in the relationship? Could you speak your mind freely, express your point of view and have equal say in the decision-making process with your spouse/partner? *
您的回答
28. Is there a history of evaluation, treatment, or hospitalization for psychiatric disorders for either party or the children? *
If yes, please describe:
您的回答
29. Have you or any member of your family ever attempted to significantly hurt yourself/himself/ herself or someone else? *
If yes, please briefly give details:
您的回答
30. If you or a member of your family have previously been in treatment, was a diagnosis given? *
If yes, what was the diagnosis?
您的回答
31. Are you or any member of your family currently in treatment? *
If yes, please let us know who is in treatment, the name of the mental health professional that person is seeing and the purpose for seeking treatment:
您的回答
32. Has any family member ever been on medication for mental health reasons? *
If yes, who is taking the medication and what is he/she taking?
您的回答
33. Have you previously been in a group therapy? *
If yes, please describe:
您的回答
34. Are you or any member of your family currently experiencing any symptoms or have any significant psychosocial or medical issues that are of concern to you? *
If yes, please describe:
您的回答
35. Do you have legal representation? *
If Yes, by whom?
您的回答
36. Have you previously participated in Mediation? *
If yes, please list the Mediator's name and dates:
您的回答
37. If you answered "Yes" to any of the above questions and would like to give more detail or share more information, please do so in the space provided:
您的回答
38. Please briefly describe the reason you are seeking services. Overall, what would you like to accomplish? *
您的回答
In the List of services provided, please check which services are of interest to you: *
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