Co-Parenting for Change Screening Questionnaire

Thank you for your interest in enrolling in Co-Parenting for Change! Co-Parenting for Change is an 8-week course that includes weekly meetings on ONE ASSIGNED NIGHT per week from 6-8 PM. All course meetings will be held via live video. To get started, please answer the questions below completely and accurately.

Paper copies are also available at the SCC office, if needed.

Today's Date:*

Date

Your Name:*

First NameLast Name

Email Address:*

example@example.com

Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

Co-Parent's Name*

First NameLast Name

1. Clinicians must speak and understand the language the clients will speak at meetings. Services at SCC are currently only offered in English. Are you willing and able to speak English at all times during the meetings?*

2. Please list the name(s) and age(s) of your child(ren): *

3. Is there a current Restraining Order/Order of Protection between you and your co-parent? (If yes, please provide SCC with a copy)*

4. Have you ever been involved in any domestic violence incidents?*

If yes, please describe the history below:

5. In the past, have you had any involvement with a child welfare agency? (DCS, Tribal, etc)*

If yes, please describe the history below:

6. Are you currently involved with a child welfare agency? (DCS, Tribal, etc)*

If yes, please describe below:

7. Have you ever been/are you currently under investigation for any formal allegations of sexual abuse between yourself and a child?*

If yes, please explain the status below. For those that have been closed, please explain the outcome:

8. Do you have any history of physical, verbal, and/or emotional abuse and/or neglect of any children?*

If yes, please describe below:

9. Is there any history of physical, sexual, verbal, and/or emotional abuse and/or neglect between any children and another parent/others living in the home?*

If yes, please describe below:

10. Do you have a criminal history for any crimes against/that involve children?*

If yes, please provide information on any convictions. Please also list if there are any pending cases and any pending charges:

11. Are you currently on probation/parole/work release/home arrest/monitored release?*

If yes, describe which:

12. Do you have a condition of release that would require SCC to verify your appointments with us, require additional paperwork, or that limits the hours/days you are able to attend appointments?*

If yes, please explain below:

13. Are you required to register as a sex offender? (if yes, please provide documentation to SCC as soon as possible)*

If yes, in what state did this crime occur?

Do you have a history of alcohol/substance abuse?*

If yes, please describe below:

14. Do you have any disabilities under the ADA that would require any accommodations or assistive technology in order to participate in this course?*

If yes, please describe below:

15. Do you have any medical conditions that may be relevant to disclose for purposes of participation in this course?*

If yes, please describe below:

16. This course guides and supports participants in understanding, developing, and improving positive communication skills, behaviors, and attitudes relevant to effective co-parenting. Please explain the goals you have for this course and what you hope to gain:*

Please upload copies of any legal documentation referenced in this form such as: Restraining Orders, Orders of Protection, and or any documentation regarding a requirement to register as a sex offender. You may also upload a copy of your Driver's License or government issued identification, if you have not provided our office with such already:

By signing below you agree that the information you have provided is accurate to the best of your knowledge. Further, you agree to inform our office in wirting in the event that any of the information contained herein has changed.

Signature:*

Printed Name:

First NameLast Name

Upload a copy of your picture ID

COPARENTING FOR CHANGE CLASS