Collaborative Co-Parenting Registration
All parental parties must register separately to participate in the program.
Name
*
First Name
Last Name
Date of Birth
*
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Payor Source
*
Please Select
Self
Montrose DHS
Delta DHS
Medicaid
For DHS, please provide Case Worker name. For Medicaid, please provide ID.
Co-Parent Name
*
First Name
Last Name
How did you hear about Collaborative Co-Parenting for High Conflict Families?
*
Is there a protection order with the co-parent?
Yes
No
File Upload for Protection Orders or other supplemental information for Parenting Plan
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Children Involved - Please include ages and Primary Parent
*
Specific Details of Parenting Arrangements
*
Areas of High Conflict
*
What’s important for our team to know to ensure a safe and successful experience in Collaborative Co-Parenting for High Conflict Families?
*
Signature
*
I understand that I am not fully registered for Collaborative Co-Parenting until all parental parties have completed separate registrations and I will be notified by Collaborative Trauma Solutions to complete an intake at that time.
*
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