Form

Needs Assessment

The following information is required in order to assess your needs and to also supply data to our potential funding bodies. This will only ever be shared anonymously and the information opens up funding opportunities for the charity to support families living with issues surrounding Parental Alienation. The charity cannot provide legal advice on individual cases. We can signpost to relevant organisations, provide guidance and support and offer general advice where possible.
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
What region do you live in?
Date of birth

Month Day Year
Date
Gender

Female Male Prefer not to say
Ethnicity
Sexuality

Heterosexual Bisexual Lesbian Gay Prefer not to say
In what capacity are you affected by Parental Alienation?

I am an affected parent Child Stepparent / partner Grandparent Friend Other family member Professional working with the client
Is the case currently, or has it previously been in the family court?

Yes No I don't know
If you answered 'yes' to the previous question do you know how long the case lasted?
Did you attend mediation prior to family court proceedings?

Yes No I don't know
If you answered 'no' to the above question what were the reasons for not attending

Ex-partner declined Domestic abuse allegations Financial difficulties Other
What sort of support are you looking for?

Legal help Emotional support Mediation Other
Please use this box to add any other supporting information you feel is relevant to help us understand the current situation.
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Needs Assessment