Fill and Sign the Child Custody Form

CHILD CUSTODY/VISITATION QUESTIONNAIRE Personal Information Full Name (including maiden):       Relationship to minor(s):       Address:       Home #:       Cell #       Work #:       SS#:       Spouse’s Full Name or person wanting/giving custody too (including maiden):       Address:       Home #:       Cell #       Work #:       SS#:       Are you and the plaintiff/defendant divorced or still married?       If divorced please state date of divorce and where the divorce was granted:       Date last separated (month/year)       Please list children from this marriage: Name Age Sex DOB SSN                                                                                                                         Note - if more than 4 children please attach additional page. General Information Have you appeared in court or agreed on terms related to this matter? Yes No Do you have copies of any documents (court decrees, dissolution agreements, etc.) related to this matter? Yes No What types of documents do you have?       Next Court Date:       Are both parities served? Yes No Court Action #:       Dept. #:       Both parties use English? Yes No Custody/Visitation Arrangements Which party desires legal custody? Client Spouse Joint Whom are the child(ren) in this matter living with now?       What was the custody/visitation arrangement when you initially separated?       How many hours/days per week?       Has the custody/visitation arrangement changed? Yes No If so, please describe the first change and any later changes and explain why the change(s) occurred and to what number of days/hours per week.       Describe the visitation schedule you are interested in obtaining:       If a change in custody has reduced or terminated your child(ren)’s contact with you, what was the reason given?       With whom will the primary residency be? Client Spouse Joint Have you previously had supervised visitation ordered? Yes No How long were you restricted to supervised visitation?       Do you currently have supervised visitation ordered? Yes No How long are you restricted to supervised visitation?       Are you or your children a victim of family violence (battering or sexual abuse)? Yes No Have you petitioned to move to another location? Yes No Where do you currently reside? City       State       Where do you plan to move? City       State       Please explain your reasons for relocating       Where does the other parent live? City       State       If you have had court hearings regarding residency or visitation, please describe what happened.       Allegations Do you want to raise any of the following issues? (Check only if allegations made) Drug/Alcohol Abuse Child Abuse Domestic Violence Child Stealing Juvenile Court Actions Is there a Restraining Order currently in place? Yes No a. What type of Restraining Order? DVPA Other Civil Criminal Emergency (EPO) Juv. Ct. Unknown Temporary b. Who does the Restraining Order restrain?       c. Who does the Restraining Order Protect?       When does it expire?       Has anyone alleged Parental Alienation Syndrome (or some other alleged scientific theory) to deprive you of custody? Yes No If other than “Parental Alienation Syndrome” is there any other theory being alleged? Yes No If so, what theory?       Were you accused of any other psychological condition which is not a valid diagnosis? Yes No If yes, describe       Miscellaneous Which party will provide healthcare? Client Spouse Joint Are parties going to share health insurance deductible/co-insurance? Yes No Will each party provide life insurance with the child(ren) as beneficiary?       Which party will claim the tax deduction allowed for child(ren)?       Are you or any person involved in this matter currently pregnant? Yes No Are parties agreeable to grandparents’ visitation? Yes No If so what visitation schedule would you like for: The Maternal Grandparents:       The Paternal Grandparents:       Financial Data A. Income Gross Income Client: $       Spouse: $       Other Income Client: $       Spouse: $       Total Gross Income Client: $       Spouse: $       Total Net Income Client: $       Spouse: $       B. Bank Information Type of Account Owner Est. Value Bank                                                                                                                         C. Debts Creditor Monthly payment Total Owed Property Mort.                                                                                                                                                                                                 Schedules Current custody arrangement/schedule Percentage of time (i.e. 50/50, 60/40, 70/30, etc.)       Pick-ups       Days and time each child is with each parent       Date that this arrangement began/ended:       How was this schedule agreed on (i.e. agreement, mediation, stipulation, court ordered, ex parte, etc.)?       Describe any other custody arrangements/schedules:       Describe your current work schedule       Do you plan to use day care? Yes No If so, how often?       Do you plan to use close family members/relatives provide child care? Yes No If so, how often?       Describe the role of the family support system (i.e. the children’s grandparents, uncles, aunts, etc.):       Where will children be when you are working?       Who will be available to watch the children while you are at work?       Previous Actions Have there ever been any allegations of domestic violence, drugs/alcohol, child abuse, etc. Yes No Has either party made sworn allegations of domestic violence against the other? Yes No If yes, who has made the allegations?       Who are the allegations against?       Has there ever been any involvement of police, child protective services, social services, etc.? Yes No Describe any OSC’s (Order to Show Cause) that have been filed:       Who brought the OSC and why (i.e. move-away, allegations of abuse, neglect, domestic violence, ex parte, etc.)?       What were the main complaints in both parties’ declarations?       Date OSC was filed, county and courthouse, name of presiding judge:       Briefly, what was the outcome of this OSC (i.e. parenting classes, custody evaluation, transfer of custody, increase/decrease in time share of children, ex parte, etc.)?       Has there ever been a Custody Evaluation? Yes No Who has made the allegations (judge, father’s attorney, court personnel, etc.)?       What other accusations have been made against you?       Have you ever been put in jail or a mental health facility because of anything directly related to your family law case? Yes No If yes, please explain.       What accusations have you made against the father?       What has happened as a result of the allegations (change in custody, visitation, etc.)?       Were findings made that you were an unfit parent? Yes No Do you have a history of mental illness? Yes No Do you have a history of drug/alcohol abuse? Yes No Do you have a criminal history? Yes No Have you gone to a mediator who listens to both sides of the dispute and then writes a report to the judge? Yes No Mediator[s] name[s]:       Were you required to mediate with an ex spouse/partner who perpetrated any form of abuse against you or your children? Yes No Did the mediator[s] issue a report[s]? Yes No Did you receive a copy of the report[s]? Yes No What did the report[s] say?       Did you disagree with the mediator’s report because it contained false, misleading, inaccurate or incorrect information? Yes No Please state what the report says and how you disagree.       Were you accused of physically or sexually abusing your child? Yes No Did you challenge the report? Yes No If yes, please explain what happened.       Did the judge make a ruling based on the mediator’s report even though you disagreed with it? Yes No Have you had a custody evaluation before an evaluator who performs factual investigations and/or psychological tests? Yes No Evaluator[s] name[s]:       Did the evaluator[s] issue a report[s]? Yes No Did you receive a copy of the report[s]? Yes No What did the report[s] say?       Please describe anything in the evaluator’s report you considered false, misleading, inaccurate or incorrect information       Did you object to the evaluator’s report? Yes No If yes, please explain what happened:       What were the proposals of each party at the beginning of the evaluation?       What were the main arguments/concerns of both parties (i.e. allegations, neglect, abuse, alcohol/drugs, unfit, move-away, school, stepparent, siblings, etc.)?       Describe the evaluation process (i.e. interviews, collateral information, psychological testing, MMPI-2, Gardner’s parenting scale, etc.):       Describe the evaluator’s recommendations (i.e. parenting classes, custody arrangement/schedule, time share with children, etc.):       Why do you think the evaluator came to this conclusion?       How long have you been involved in contested custody proceedings?       Has the judge ever issued a final judgment to end the proceedings after an award of custody? Yes No Have you tried to appeal the custody order? Yes No If yes, was the case ever set up for appeal? Yes No If no, what happened to the appeal?       Health Concerns State the physical health, any chronic illness or medicine taken regularly of all parties to this action:       State the mental health history, marriage counseling or hospitalizations of all parties to this action:       Are any mental/emotional health problems related to divorce/custody disputes or to long- term instability? Yes No Has there been any drug and/or alcohol involvement by either party or stepparents? Yes No If yes, how much; what treatment has been sought; and what has that individual’s response been to that treatment?       Moral Issues Are there any romantic relationships by either party? Yes No If yes, how have the relationships affected the child?       Is foul language used by either party in front of the child? Yes No If yes, what effect has the language been on the child?       What do you see as your strengths and weaknesses or your moral beliefs?       What are the other party’s strengths and weaknesses or moral beliefs?       Family Relations Explain briefly, your relationship with other parent and your children:       How and why the relationship dissolved (please describe briefly)?       Describe your relationship with your children:       Describe the children’s relationships with the other parent:       What is the child’s relationship to other siblings?       How do you think the child perceives the family unit?       What future home is proposed by the petitioning party; and what future relationships would that involve?       Do you have any immediate prospects of remarriage or a continuing relationship with a person who will be involved in the life of the child?       Describe the present custodial home:       Describe the proposed custodial home (i.e., Is it in the same geographic location?)       (How will a move affect the child?):       Who sleeps where in each home?       Describe the housekeeping standards of each home:       What is the address of the custodial home; the length of time in the home; and who lives there?       Parenting Responsibilities Who purchases the children’s clothes, toys, and other equipment?       Who arranges for and takes the child to doctor/dentist appointments?       Who arranges for the babysitter/child care?       Are there any special needs of the child (medical, educational, speech, etc.)?       What is being done about these special needs and which party is attending to this? Who is better able to deal with this?       How well do you manage money?       Please state your answer and the degree of responsibility you and your spouse should have regarding each of the following: Education       Religious training       Discipline       Moral values       Medical and dental       Psychological and psychiatric care       Social activities       Extracurricular activities Recreational activities       Legal care       Financial involvement       Summer camp, travel and activities Other (please list)       Custody Award Do you believe the custody award was unfair? Yes No Do you suspect that you were discriminated against in the child custody award because of your gender, race, class, culture, ethnicity or sexual orientation? Yes No Do you suspect that you were discriminated against in the child custody award because of the relationship between any court personnel? Yes No If Yes, please explain:       Do you suspect that you were discriminated against in the child custody award because the judge and/or attorneys or any other court personnel? Yes No Were you not represented by an attorney at any time in the proceedings? Yes No Did your child(ren) have an attorney at any time in the proceedings? Yes No