GAL Initial Information
Please provide as much detail as possible
Your Name
*
First Name
Last Name
Aliases/Prior Names
Relationship to the Child(ren)
Your Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Current Housing Status:
Own
Rent
Other
Your Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Can we send text messages to this number?
Yes
No
Your Email Address
*
example@example.com
Prior Address(es) (Last Two Years)
Employment and Income Information
Your Employer:
Occupation:
Date of Hire:
Prior Employment (Last 2 Years):
Reason(s) for Leaving Employment:
Do you have other sources of income in your household?
Social Security
Retirement income
Additional adult my household helps with my expenses
Other
Children Information
Custody
Who has custody of the child/children?
What is your current Parenting Time Schedule?
How long has child been at current residence?
Do You or Any Household Member(s) Own / Possess a Firearm?
Yes
No
Is Firearm Licensed / Registered?
Yes
No
Number of Firearm(s) in Residence:
Location of Firearm(s) in Residence:
Do You or Any Household Member(s) Smoke?
Yes
No
Do You or the Household Member(s) Smoke Around the Children?
Yes
No
School (If Applicable):
Grade:
Teacher:
Grades/GPA:
Attendance/Disciplinary Issues:
School Counselor (If Applicable):
Special Education?
Yes
No
If "Yes", Please Explain:
Daycare Provider:
In-Home?
Yes
No
If "No", Address:
Weekly Cost:
Health Insurance Provider:
Weekly Cost (Children ONLY)
Primary Care Provider:
Date of Last Visit:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Last Visit:
Chronic/Recurring Conditions:
Prescribed Medication(s):
Counseling/Counselor (Past or Present):
Reason(s) for Counseling:
Child-Related Concerns (i.e. Suicidal Ideations; Abuse):
Child(ren)'s Three (3) closest Friends:
Child(ren)'s Talents:
Child(ren)'s Hobbies:
Parenting Time Overnights (Non-Custodial Parent) (Annual):
Case Information
List ALL Children (Biological and Step-Children) and Following Information:
List ALL Persons Currently Residing at Your Residential Address:
List ALL Grandparents, Close Relatives, or Friends with Significant Relationship with Children:
Do you have Military Service?
Yes
No
Please State Military Branch
Your Education:
Please Select
Did Not Finish High School
High School Grad
GED
Technical/Trade
College
Post-Grad
Relationship/Marital History with Opposing Parent
Date(s) of Relationship:
Married?
Yes
No
Current Status of Relationship:
Household Information
Marital / Relationship Status:
Single
Married
Divorced
Widowed
Name of Significant Other (if applicable):
First Name
Last Name
Significant Other's Contact Information:
Significant Other's Employer:
Length of Relationship:
Significant Other's Children:
List ALL Chronic/Recurring Health Issues as to ALL Household Members:
List ALL Alcohol/Drug Usage of ALL Household Members:
List ALL Criminal Histories for ALL Household Members:
List ALL Counseling/Therapy Histories of ALL Household Members:
List ALL Domestic Violence/Physical/Sexual Abuse Histories for ALL Household Members:
List ALL Dep't of Child Services Histories for ALL Household Members:
List ALL Child Custody-related Litigation for ALL Household Members:
Are there now, or have there ever been, previous orders filed between parties?
If yes, when?
Miscellaneous Information
Please Describe Your Parenting Style:
Please Describe Other Parent's Parenting Style:
How do you discipline the children?
How does the other parent discipline the children?
Please Describe Any of Your House Rules:
Why Should You Have Custody of the Children?
What Concerns Do You Have as to the Other Parent/Other Household?
What Concerns Do You Believe the Other Parents Has as to You/Your Household?
What Are You Doing to Affect Your Future Relationship with the Other Parent?
What concerns would you like the GAL to look into?
What outcome do you hope for?
If You Would Like the GAL to Contact Any Other Parties, Please List ALL Such Persons:
The undersigned hereby verifies that this form has been completed to the best of my knowledge and ability:
Submit
Should be Empty: