Date(mm/dd/yy)

Your Name

Home Phone

Work Phone

Cell Phone

Address

Address Line 2(opt.)

City

State Zip Code

Date of Birth(mm/dd/yy) Marital Status

Employer

Occupation

Make & Model of Vehicle

License Plate Number State

Driver’s License Number State

Other Parent's Name

How To Contact Him/Her

Have you ever been convicted of a crime?(Y/N)

Conviction for?

Felony or Misdemeanor?

Has other parent ever been convicted of a crime?(Y/N)

Conviction for?

Felony or Misdemeanor?

Please List the Children Involved In Parenting-Time:

Child #1

Name

Date of Birth(mm/dd/yy) Age Gender(M/F)

Residing with

Child #2

Name

Date of Birth(mm/dd/yy) Age Gender(M/F)

Residing with

Child #3

Name

Date of Birth(mm/dd/yy) Age Gender(M/F)

Residing with

Child #4

Name

Date of Birth(mm/dd/yy) Age Gender(M/F)

Residing with

Child #5

Name

Date of Birth(mm/dd/yy) Age Gender(M/F)

Residing with

Please summarize the events that have initiated supervised or therapeutic parenting-time:

How is your relationship with your child/children at this time?

What outcome or goals do you hope to achieve regarding parenting-time?

Do you have any special concerns for the child/children? Are they having any problems?

Please describe any medical conditions and/or medications that would effect your child/children during parenting-time:

Please provide the following information for other professionals involved:

Attorney

Phone

Child Family Investigator

Phone

Guardian Ad Litem

Phone

Therapist

Phone

Social Services Caseworker

Phone

Other

Phone