Intake Form for Custody/Access Cases

Office of the Children’s Lawyer Intake Form

The court has asked the Office of the Children’s Lawyer to provide a lawyer for the children and/or a clinician to meet with you and the children to help the judge decide your case. Your answers will help the Office of the Children’s Lawyer decide whether it can help.

Section 1: Tell us about yourself

a. Your full legal name:

b. Any other name you go by:

c. Your date of birth:

d. You are the applicant applicant respondent in the case before the court

e. Your relationship to the children:

f. Where you were born:

g. Where you live (including postal code):

h. Your email address:

i. Your telephone number during the day:

j. Your telephone number in the evening:

k. The best way to contact you:

l. Where you work:

m. What you do:

n. Your lawyer’s name and address:

o. Your lawyer’s phone number:

p. Your lawyer’s fax number:

q. Languages you speak: English French Other

r. Languages the children speak: English French Other

s. You prefer to receive services in: English French

t. The children should receive services in: English French Other

Section 2: Tell us about the other party

a. Full legal name:

b. Any other name the other party goes by:

c. Date of birth:

d. Other party’s relationship to the children:

e. Where the other party was born:

f. Where the other party lives (including postal code):

g. Lawyer’s name:

h. Lawyer’s address:

i. Lawyer’s phone number:

j. Lawyer’s fax number:

Section 3: Tell us about the children

a. The number of children involved in the custody/access case before the court is

b. The children’s names and dates of birth:

c. The children go to school and/or daycare at:

d. Are any of the children members of a First Nation? Yes No

If yes, tell us the name of the First Nation, band or native community:

e. Do any of the children have any special emotional, psychological, educational or physical needs? Yes No I don’t know

Are you able to meet the child’s needs? Yes No

Are there any problems with the other party/parties being able to meet the child’s needs? Yes No

Section 4: Previous involvement of the Children’s Lawyer or other assessors

1. Have you, any other party or the children ever been involved with the Office of the Children’s Lawyer? Yes No

If yes, when?

Did the Office of the Children’s Lawyer provide a clinical investigator? a lawyer? both?

Who was it?

2. Has a social worker, psychologist or psychiatrist been involved with your family to help with or make recommendations about parenting or custody and access issues? Yes No

If yes, who was it?

Section 5: Tell us about ways you have tried to resolve your issues

1. Have you been to a mandatory information program? Yes No

2. Have you and the other party tried mediation? Yes No

3. Are you interested in exploring mediation? Yes No

4. Have you been told by a mediator that your case is not appropriate for mediation? Yes No

5. If you have tried mediation, were you able to resolve any of the issues? Yes No

Section 6: Tell us about your relationship with the other party

1. You married lived together, but did not marry never lived together other

(please specify):

2. When did you begin your relationship?

3. When did you separate?

4. You and the other party are: divorced separated other

(please specify):

5. Are you and the other party currently living in the same house? Yes No

6. You and the other party are able to communicate about the children: most of the time some of the time through a third party in writing only not at all

Section 7: Tell us about the people who live in your home

Do not include the children who are before the court in this case. Not applicable

Full Legal Name / Date of Birth / Relationship to you

What involvement, if any, do these people have with the children?

Section 8: Tell us about the children’s living and visiting arrangements now

1. Who are the children living with now?

2. What is the access schedule?

3. Do you think the current arrangements are good for the children? Yes No

4. Have the custody and access arrangements for the children changed? Yes No

5. Is (are) one or more child(ren) refusing to see a parent? Yes No

6. Have you signed an agreement about custody or access? Yes No

When?

7. Has the court made a custody or access order? Yes No

If yes, how many orders?

The order is temporary final

8. Is the most recent order or agreement being followed? Yes No

9. When is your next court appearance?

10. What type of hearing is the case scheduled for?

Case conference Settlement conference Motion Trial management conference Trial

Section 9: Tell us what orders you are asking the court to make

Custody

Sole custody to you

Joint custody between you and

Other (please specify)

The children shall have their primary residence with

Why?

Access

Access to as follows:

Access to me as follows:

Why?

Supervised access to

Why?

No access to

Why?

Mobility

An order permitting you to move with the children

Where?

Why?

If you are allowed to move, how and when will the children see and have contact with the other party?

An order preventing the other party from moving with the children

Where?

Why?

An order preventing the other party from taking the children outside of the jurisdiction

Why?

Restraining Order

A restraining order against the other party

Terms of the restraining order you are asking for:

Why?

Support or Property

Child support Spousal support Division of property

Exclusive possession of the matrimonial home

Section 10: Children’s Aid Society Involvement

Are you, your children or anyone who lives with you involved with a children’s aid society now? Yes No

If yes, when did the CAS become involved?

Have you, your children or anyone who lives with you ever been involved with a children’s aid society? Yes No Don’t know

1. Is one or more of your children currently in the care of a CAS? Yes No

If yes, who?

When did he/she/they go into care?

The child is in care under a: special needs agreement temporary care agreement court order

2. When was the CAS involved?

3. Who was the CAS involved with?

4. What are or were the children’s aid society’s concerns?

Neglect Physical abuse Sexual abuse Emotional/psychological abuse Adult conflict Domestic violence Parent/teen conflict Other

Section 11: Violence or abuse

Was there violence or abuse between you and the other party or against the children? Yes No

Who was the abusive party?

When did the violence occur? While you were together Since separation Currently

What type of violence? Physical Emotional/Psychological Verbal Sexual Other

Were you injured? Yes No

Was the other party injured? Yes No

When did this happen?

Have you ever been stalked/followed/threatened by the other party? Yes No

Are you afraid of the other party? Yes No

Are the child(ren) aware of the violence or abuse? Yes No

Was there violence/abuse against the child(ren)? Yes No

Section 12: Tell us about your involvement with the police

Have you ever been involved with the police? Yes No

Name of police services:

Date(s) of involvement:

Has a court ever made a restraining order against you? Yes No

If yes, when?

Date of restraining order:

Expiry date of restraining order:

Are you subject to a peace bond? Yes No

I have been found guilty of the following criminal offence(s):

Are you subject to probation conditions? Yes No

Section 13: Tell us what you know about the other’s party’s involvement with the police

Has the other party ever been involved with the police? Yes No Don’t know

Name of police services:

Date(s) of involvement:

Has a court ever made a restraining order against the other party? Yes No Don’t know

Date of restraining order:

Expiry date of restraining order:

Is the other party subject to a peace bond? Yes No Don’t know

The other party has been found guilty of the following criminal offence(s):

Is the other party subject to probation conditions? Yes No Don’t know

Section 14: Tell us about health issues

1. Do you have mental health issues? Yes No

If yes, have you been diagnosed by a mental health professional? Yes No

What is the diagnosis?

2. Are you in treatment? Yes No

If yes, name of doctor/therapist:

Have you been prescribed medication? Yes No

3. Does the other party have mental health issues? Yes No Don’t know

If yes, was he/she diagnosed by a mental health professional? Yes No Don’t know

What is the diagnosis?

4. Is the other party in treatment? Yes No Don’t know

If yes, name of doctor/therapist:

Has the other party been prescribed medication? Yes No Don’t know

Is the other party taking medication as prescribed? Yes No Don’t know

5. Do the mental health issues have an impact on the children? Yes No

6. Does anyone have other health issues? Yes No

7. Do these health issues impact on the person’s ability to care for the children? Yes No

Section 15: Tell us about substance abuse issues

1. Have you ever had a problem with substance abuse? Yes No

If yes, what type of substance abuse? Alcohol Drugs

(specify):

Provide details of any treatment you have received:

2. Has the other party ever had a problem with substance abuse? Yes No Don’t know

If yes, what type of substance abuse? Alcohol Drugs

(specify):

Provide details of any treatment he or she has received:

3. Did the substance abuse have an impact on your relationship with the other person or the children? Yes No

Remember: You must attach the following documents to this form:

A copy of the order appointing the Children’s Lawyer in your matter

A signed consent form to allow the Office of the Children’s Lawyer to obtain your police records

Signed consent form(s) to allow the Office of the Children’s Lawyer to obtain the police records of anyone other than the children who is currently living with you

A signed consent form to allow the Office of the Children’s Lawyer to obtain information from any children’s aid society that has been involved with you or your children

Signed consent form(s) to allow the Office of the Children’s Lawyer to obtain information from any children’s aid society that has been involved with anyone other than the children who is currently living with you

A copy of any completed custody and access assessments

A copy of any current custody and access orders

A copy of any current child protection orders, agreements you have entered into with a CAS or letters from a CAS describing their involvement with you, your family or anyone living with you

A copy of any current restraining order, probation order, peace bond or bail conditions

Certification

I certify that I have reviewed the contents of this form and that the information is accurate and true.

Jurisdiction

You and the children must go to interviews and meetings in the same region where the Court that is hearing your custody and access case is located. If you do not agree, the OCL will not consider your request. Please sign below to indicate that you agree to this condition.

Consent Form for Release of Children’s Aid Society Records

TO: (children’s aid society)

Name of case:

Court File No.: OCL Case No.:

My last name is

My first name is

My middle name(s) are (if any)

I have also used or been known by the following last names:

I have also used or been known by the following names:

I was born on (year, month, day)

The names and dates of birth of my children are:

My address is

I have also lived at the following addresses in the last five years: (Give approximate dates)

I authorize the Office of the Children’s Lawyer and its agents to collect, use and disclose any information obtained in the course of providing service to the above named child(ren), including, but not limited to, preparing and writing a report for the Court.

Name of city, town or municipality where signed:

Consent Form for Release of Police Records

TO: (local police service)

Name of case:

Court File No.: OCL Case No.:

My last name is

My first name is

My middle name(s) are (if any)

I have also used or been known by the following last names:

I have also used or been known by the following names:

I was born on (year, month, day)

The names and dates of birth of my children are:

My address is

I have also lived at the following addresses in the last five years: (Give approximate dates)

I authorize the Office of the Children’s Lawyer and its agents to collect, use and disclose any information obtained in the course of providing service to the above named child(ren), including, but not limited to, preparing and writing a report for the Court.

Name of city, town or municipality where signed: