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Guardian ad Litem Questionnaire
Encrypted
Secure Form
1
What's your name?
*
This field is required.
This helps us keep track of who we've heard from!
First Name
Last Name
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2
How should we address you?
For example, John Smith, M.D. may prefer "Dr. Smith," "John," "J," or "Mr. Smith."
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3
What's your email?
example@example.com
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4
What's your phone number?
Area Code
Phone Number
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5
What's the child's name?
*
This field is required.
First Name
Last Name
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6
What are the child's pronouns?
*
This field is required.
He/Him
She/Her
They/Their
Ze/Zim
Zie/Hir
Zie/Zir
Ey/Em
Per/Per
I don't see the child's pronouns.
He/Him
She/Her
They/Their
Ze/Zim
Zie/Hir
Zie/Zir
Ey/Em
Per/Per
I don't see the child's pronouns.
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7
What's your relationship to the child?
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8
What's the child's birthday?
*
This field is required.
-
Date
Month
Day
Year
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9
Where was the child born?
*
This field is required.
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10
What's the child's social security number?
The Court will often use this to distinguish children with the same name apart from one another. We may also need to add it to confidential addendums for the Court's records. If you'd prefer to give this information over the phone, call (804) 548-6565.
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11
Health & Wellness
Please answer the following questions as they relate to the child.
Medical Insurance Provider
Name of Pediatrician
Pediatrician's Phone Number
Please describe the child's physical & mental condition.
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12
School & Daycare
School Name
School Phone
Day/Child Care Provider Name
Day/Child Care Phone
Cost of Day/Child Care
How often in daycare?
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13
Delinquency History
Please describe any instances in which the child has been charged with any crimes or delinquent acts even if the charges were dropped or the child wasn't put in jail.
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14
Where will the child live?
Please provide the address for where you would like the child to live after this case is resolved.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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15
Other Occupants
Please list the names, ages, and relationships other people that will live in the home with the child. Please format as: Jane Doe, 21, Sister
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16
Home Information
Number of Bedrooms
Number of Bathrooms
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17
Home Information (Continuted)
Please check all that are present in the home.
Living Room
Dining Room
Family Room
Living Room
Basement
Kitchen
Front Yard
Backyard
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18
Home Information (Continued)
Please describe the neighborhood.
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19
Home Information (Continued)
Please list any family or friends in the neighborhood.
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20
What are the child's favorite activities?
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21
What are the child's favorite foods?
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22
What size of clothes does the child wear?
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23
Does the child have any special needs? If so, please describe. If not, please click "Next."
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24
Please describe the child's daily schedule, extracurricular activities, counseling, etc.
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25
Have you already completed this form for another child involved in this matter?
YES
NO
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26
What was the name of the first child for whom you completed this form?
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27
Where are you currently living?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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28
How long have you been at that address?
A rough estimate is ok!
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29
Did you live with the child anywhere before your current address?
YES
NO
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30
What's the prior address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
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Portugal
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Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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31
How long did you live there?
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32
Have you lived anywhere else with the child?
*
This field is required.
YES
NO
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33
Please list the other addresses where you've lived with the child.
Please include the address and length of time you lived there.
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34
How long have you lived in Virginia?
*
This field is required.
Please include the entire time you've lived with the child; including any time you lived in Virginia without the child.
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35
Please list the names, ages, and relationship to you for all persons who live with you in the home.
Please format as: Jane Doe, 21, Sister
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36
What is your citizenship?
*
This field is required.
Please provide the name of the country where you are a citizen. If you are a citizen of the United States, please simply write "USA."
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37
When is your birthday?
*
This field is required.
We may need this for various Court filings.
-
Date
Month
Day
Year
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38
What is your social security number?
The Court will often use this to distinguish children with the same name apart from one another. We may also need to add it to confidential addendums for the Court's records. If you'd prefer to give this information over the phone, call (804) 548-6565.
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39
Are you currently incarcerated?
*
This field is required.
YES
NO
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40
Incarceration Information
Please complete the following fields as they relate to the charge(s) for which you are currently incarcerated.
When did you sentence start?
How long is your sentence?
Which court sentenced you?
What are your charges?
Expected release date
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41
Do you have any other children?
*
This field is required.
Please answer "yes" if you have any other children, even if they do not play an active role in the child's life.
YES
NO
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42
How many other children do you have?
0
1
2
3
4+
0
1
2
3
4+
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43
Child 1's Information
Name
Age
Parents
Please describe the role this child plays in the child's life.
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44
Child 2's Information
Name
Age
Parents
Please describe the role this child plays in the child's life.
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45
Child 3's Information
Name
Age
Parents
Please describe the role this child plays in the child's life.
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46
Additional Children
Please list the name, age, parents, and role the child plays in the child's life for all additional children.
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47
Your Parents
The Court often considers additional family members as a form of support for children.
Mother's Name
Please Select
Living
Deceased
Unknown
Please Select
Please Select
Living
Deceased
Unknown
Living or Deceased
Father's Name
Please Select
Living
Deceased
Unknown
Please Select
Please Select
Living
Deceased
Unknown
Living or Deceased
Stepmother's Name
Please Select
Living
Deceased
Unknown
Please Select
Please Select
Living
Deceased
Unknown
Living or Deceased
Stepfather's Name
Please Select
Living
Deceased
Unknown
Please Select
Please Select
Living
Deceased
Unknown
Living or Deceased
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48
Please describe your relationship with your parents.
This will help the Court evaluate the level of support your parents may be able to provide for the child.
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49
Please list your siblings below.
As with your parents, the Court will often consider siblings as a possible means of support for the child. Please list your siblings' names, ages, and their relationship to you below. Please format as: Jane Doe, 21, Sister
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50
Were you ever married to the child's other parent?
*
This field is required.
YES
NO
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51
Marriage Information - With Other Parent
When were you married?
How long were/have you been married?
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52
Are you separated or divorced from the child's other parent?
YES
NO
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53
Separation & Divorce Info - From Other Parent
When were you separated?
When were you divorced?
Where were you divorced?
What were the grounds for your divorce?
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54
Are you currently married to someone other than the child's other parent?
YES
NO
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55
Spouse's Information
Name
Where is your spouse originally from?
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56
Have any other romantic partners lived with both you and the child (other than your current spouse and/or the child's other parent)?
YES
NO
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57
Other Partners' Information
Name
Time you lived with them
Please Select
Yes
No
Unknown/Disputed
Please Select
Please Select
Yes
No
Unknown/Disputed
Do you have kids with them?
Name
Time you lived with them
Please Select
Yes
No
Unknown/Disputed
Please Select
Please Select
Yes
No
Unknown/Disputed
Do you have kids with them?
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58
Are you employed?
YES
NO
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59
Please upload your resume.
Please ensure your current employer is listed. If you do not have a resume, please click "Next."
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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60
Employment Information
Last Employer
Please Select
Yes
No
Please Select
Please Select
Yes
No
Are you still working here?
Salary/Wage
Supervisor
If you were terminated from this position, describe why.
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61
Have you ever been convicted of a crime?
Please DO NOT include traffic charges, unless they were a DUI, DWI, or felony.
YES
NO
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62
Please describe your prior charges.
Please format at: Charge, City/County, Date
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63
Are you currently on parole?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Yes/No
PO's Phone Number
PO's Jurisdiction
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64
Drug Use
Please check all that apply.
I currently use illicit substances.
I currently consume cannabis or substances containing THC.
I have gotten treatment for drug use.
I regularly drink alcohol.
I have gotten treatment for alcohol use.
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Drug Use (Continued)
You indicated you currently use illicit substances. Please tell us more about that.
Please list the substances you currently use.
Which substance(s) do you use most frequently?
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66
Drug Use (Continued)
You indicated that you
How often do you use/consume cannabis?
How do you normally consume cannabis (smoke, edibles, etc.)
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67
Drug Use (Continued)
You indicated that you regularly consume alcohol. Please tell us a bit more about that.
How often do you consume alcohol in a typical week?
How much do you drink when you do?
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68
Drug Use (Continued)
You indicated that you have received treatment for drug use. Please tell us a bit more about that.
Where did you receive treatment?
When did you receive treatment?
For what substance did you receive treatment?
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69
Drug Use (Continued)
You indicated that you have received treatment for alcohol use. Please tell us a bit more about that.
Where did you receive treatment?
When did you receive treatment?
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70
Do you have any health problems?
"Health" means both physical and mental health problems.
YES
NO
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71
Please describe any problems you have with your physical health.
Please include any diagnoses or general issues you may be having.
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72
Please describe any problems you have with your mental health.
Please include any diagnoses or general issues you may be having.
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73
Please list the medications you are currently taking and the conditions those medications treat.
Please format as: Prozac, Depression.
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74
Are you undergoing any therapy or treatment?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Yes/No
If yes, what's your therapist's name?
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75
Your Education
Please Select
Some High School
High School Diploma
GED
Some College
Bachelor's
Trade School
Other
Please Select
Please Select
Some High School
High School Diploma
GED
Some College
Bachelor's
Trade School
Other
Highest Level of Education
Date of Highest Degree or Certificate
Please describe your degrees or certifications.
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76
Has a Custody or Visitation Order been entered concerning the child?
YES
NO
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77
How many Custody or Visitation Orders have been entered concerning the child?
1
2
3
4+
1
2
3
4+
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78
Most Recent Custody/Visitation Order
Date Ordered
Issuing Court
Custody Awarded
Visitation Awarded
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79
Prior Custody/Visitation Order
Date Ordered
Issuing Court
Custody Awarded
Visitation Awarded
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80
Prior Custody/Visitation Order
Date Ordered
Issuing Court
Custody Awarded
Visitation Awarded
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81
Additional Custody and Visitation Orders
Please list any additional custody or visitation order history below. Be sure to include:
the date ordered, issuing court, and the details of the order(s).
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82
Do you pay child support for any children?
YES
NO
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83
How much do you pay in total for child support?
Please include the amounts you pay for children other than the child involved in this case.
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84
Do you pay child support for the child in this case?
YES
NO
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85
How much do you pay in child support for the child in this case?
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86
Have you filed a petition for child support in connection with this matter?
YES
NO
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87
Does the child receive any benefits for Social Security?
YES
NO
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88
Social Security Benefits
Type of benefits
Amount per month
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89
What is your annual income?
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90
Have you filed all of your taxes for the last 5 years?
YES
NO
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91
Do you wish to have custody of the child?
YES
NO
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92
What kind of removal from your custody would you prefer?
Permanent
Temporary
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93
Why are you seeking custody?
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94
What are your strengths as a parent?
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95
What are the areas you can improve as a parent?
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96
What are the strengths of the other parent?
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97
What are the areas the other parent can improve as a parent?
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98
How do you plan to actively support the child's relationship with the other parent?
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99
Describe your relationship with the child.
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100
Describe your ability to meet the emotional, intellectual, and physical needs of the child.
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101
Describe the child's relationship with extended family, including: siblings, peers, and other family members.
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102
Has the other parent unreasonably denied visitation with or access to the child? If so, describe.
If the other parent has not unreasonably denied visitation with or access to the child, please simply write "n/a" or click "Next."
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103
What activities do you enjoy with the child?
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104
Describe how you discipline the child.
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105
Please describe any history of domestic violence in the home.
Please include any instances of violence or unreasonable anger displayed by the other parent.
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106
Please describe any history of Child Protective Services (CPS) complaints involving you or the child.
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107
Describe the physical and mental of the other parent.
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108
Describe the role each parent has and will continue to play in the upbringing and care of the child.
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109
Describe the relative willingness and demonstrated ability of each parent to maintain a close and continuing relationship with the child, and the ability of each parent to cooperate in and resolve disputes regarding matters affecting the child.
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110
What are the child's preferences and why?
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111
Please describe the changing developmental needs of the child.
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112
Additional information about other parent, such as Criminal and/or Serious Traffic Offenses, Drug and/or Alcohol Abuse, Mental Health Conditions, or Other information you deem pertinent or important to the inquiry in this matter.
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113
What's your religious affiliation, if any?
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114
What else would you like me to know about the other parent?
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115
What else would you like me to know about you or the child?
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116
Who would you like me to contact, if anyone?
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117
What are your goals for the child?
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