Client Intake Questionnaire
The State of Minnesota requires a thorough interview process. This includes a gathering of information to determine safety risks and needs. You will need to provide a copy of your Driver's License or photo ID, copies of all Court documents relating to case (divorce, custody, supervised visitation order, protective order, etc.) Additionally, provide a report of written records related to Domestic Violence, a report of allegations of abuse or substantiated abuse, child/ren health and any special needs to consider. Information received during this process and future engagement with The Price Dynamic is confidential. *We do not share contact information or addresses with your co-parent.
Name
First Name
Last Name
Family Law Case Number
Next Court Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which of our services are you interested in?
Supervised Visitation
Monitored Exchange
One-on-One Coaching
Transitional Visitation
Parent Education Classes
Reunification Support
What County is your Family Case in?
Hennepin
Anoka
Dakota
Ramsey
Scott
Other
Emergency Contact
First Name
Last Name
Emergency Contact Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Are you represented by an attorney
Yes
No
Attorneys Name
First Name
Last Name
Attorneys Email
example@example.com
Vehicle Year, Make, Model & Color
What is the name of your co-parent
First Name
Last Name
What is your understanding of why Supervised Visitation is needed?
Back
Next
Please list the name and date of birth of the child/ren visiting (ie. James, 05/01/22)
Have you or the other parent ever said there is a concern about family violence?
Yes
No
Not Sure
If yes, please describe below
Has a request for protection (restraining) order been filed by either parent against the other parent/ child/ren in the past five years?
Yes
No
Not Sure
If yes, please describe below
If yes, does the restraining parent own weapons?
Do you have any concerns about the safety of the children?
Yes
No
Not Sure
If yes, please describe below
Do you have any concerns about your safety when you are around the other parent?
Yes
No
Not Sure
If yes, please describe below
Do you have any concerns about substance use (drug, alcohol or prescription) by the other parent?
Yes
No
Not Sure
If yes, please describe below
Are there any mental health issues impacting the other parent or child/ren?
Yes
No
Not Sure
If yes, please describe below
Is there a written report of suspected or substantiated abuse by the other parent?
Yes
No
Not Sure
If yes, please describe below
Do you or your child/ren have any health issues your monitor should know about?
Yes
No
Not Sure
If yes, please describe below
When is the last time you and your child/ren were together? Please Describe
Attachment (Driver's License/ Photo ID, Court Order, Etc)
*
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Please attach your most recent court order or SENE Agreement (ie. Documentation granting you parenting time). TPD will not schedule an intake appointment with a client that does not have formal documentation. (photos of documents are acceptable)
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Date
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Month
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Day
Year
Date
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