Your Name *

First Name

Last Name

Your Phone

Cell

(###)

###

####

Attorney phone:

(###)

###

####

Name of other party involved in this case

First Name

Last Name

Phone of other party named in case

(###)

###

####

Other Party's Attorney (if you know it)

First Name

Last Name

Your Date of birth

MM

DD

YYYY

Your DL Expiration

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone

(###)

###

####

Please indicate the status of your relationship with your child(rens) other parent

Divorce

Separated

Paternity

Domestic Violence

Date of Marriage

MM

DD

YYYY

Date of Separation

MM

DD

YYYY

Date filed for divorce

MM

DD

YYYY

Date divorce final

MM

DD

YYYY

Step-parent or significant other living in your home?

Yes

No

If YES, name:

First Name

Last Name

Date of Birth

MM

DD

YYYY

Date or remarriage (if applicable):

MM

DD

YYYY

Child's Physician:

First Name

Last Name

Child's Physician Phone:

(###)

###

####

Do you believe that there is a problem with drugs or alcohol?

By you

By Ex-spouse / Ex-partner

Who presently has legal custody of the child(ren)?

Father

Mother

Joint

Not determined at this time

Who presently has physical custody of the child(ren)?

Father

Mother

Joint

Not yet determined at this time

The decision for previous visitation agreements were made by/with the assistance from:

You and your ex-spouse / ex-partner

Counselor or Mediator

Judge or Attorney

What was the date of the last contact between visiting parent and the child(ren)?

MM

DD

YYYY

How would you best describe your command of the English language?

No interpreter needed

I can get by without a bi-lingual staff or interpreter

I prefer to have someone present who speaks my native language

I must have an interpreter or bi-lingual staff at all times