Co-Parenting for Change Screening Questionnaire

Thank you for your interest in enrolling in Co-Parenting for Change! CPFC 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

Is there a different name that you prefer we call you?

Gender:

Date of Birth:

Date

Email Address:

example@example.com

Phone Number:

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

Is it OK to leave a message?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation:

Emergency Contact Name:

First NameLast Name

Emergency Contact Relationship

Emergency Contact Phone Number

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

Co-Parent's Name

First NameLast Name

Is your co-parent also taking this course?

While you and your co-parent may take this course at the same time, you will be in different classes. In weeks 6 and 8, if your co-parent took the course in the past or is taking it this round, your class time will be together with a facilitator for practice. If they take the course in the future, we can bring you back in for your co-parent's week 6 and 8 to practice the skills and you will be assigned in this round to practice the skills in weeks 6 and 8 with another member of the class. Is there any LEGAL reason that prohibits either of you from this practice?

Explain:

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?

Please list the name(s), age(s), and gender(s) of your child(ren):

Is there a current Restraining Order/Order of Protection between you and your co-parent? (If yes, please provide SCC with a copy using the submission portal at the end of this application)

Have you ever been involved in any domestic violence incidents?

If yes, please describe the history below:

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

If yes, please describe the history below:

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

If yes, please describe below:

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:

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

If yes, please describe below:

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:

Do you have a criminal history for any crimes against or that involve children?

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

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

If yes, describe which:

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:

Are you required to register as a sex offender? (if yes, please upload legal documents in the portal at the end of this application)

If yes, in what state did this crime occur?

Do you have a history of alcohol/substance abuse and/or treatment for this as an issue?

If yes, please describe below:

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:

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

If yes, please describe below:

Are you in therapy or prescribed mental health medications? Please explain below:

Have you had any mental health hospitalizations? Please explain:

What is your current parenting plan? Please describe the schedule below:

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:

How were you referred to this program?

Are you mandated to take this class? If Court Ordered, please upload a copy of the order in the secure portal at the end of this form.

Attorney's Name (if applicable)

First NameLast Name

Attorney's Email

example@example.com

Attorney's Phone Number

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

Probation/Parole Officer's Name (if applicable)

First NameLast Name

Probation/Parole Officer's Email:

example@example.com

Probation/Parole Officer's Phone Number:

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

This is a HIPAA compliant, secure portal. 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. We must also have a copy of your Driver's License or government issued identification on file which you can upload below if you have not provided our office with such already:

The cost of this class is $315 via Zelle or $320 via credit card. Links are listed below.

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Cost of $315 via Zelle

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$315.00 Quantity

Cost of $320 via Credit Card

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$320.00 Quantity

Total

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

COPARENTING FOR CHANGE CLASS

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