Parent Questionnaire

Minor's Counsel - Parent Questionnaire
Before returning this questionnaire to our office you may want to talk to your attorney and ask whether or not he or she wishes to go over the information you have provided. The information on this questionnaire is very important. This questionnaire must be filled out completely and returned as soon as possible.
General Information
Your Name (submitted by)

First NameLast Name
Case Name
Case Number
Your Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived at this address?
Do you rent or own?

OwnRent
Home Number
Please enter a valid phone number.
If you do not have a telephone, please write down a number that we can reach you.
Please enter a valid phone number.
Work History
What kind of work do you do?
Who do you work for?
How many years?
Your Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Please enter a valid phone number.
What days and hours do you work? Include when you leave for work and when you return from work.
Do you regularly work overtime? List what days and how many hours you work overtime.
Does your job require you to travel outside of the local area for more than 24 hours at a time? If so, describe how often this happens and how far in advance you are able to know that you will be required to travel.
What is the highest grade level in school/ degree you have completed?
Additional Personal Details
Date of Birth

MonthDayYear
Date
Do you have a valid driver's license?

YesNo
Claims
Are you claiming the other party has been physically abusive to you?

YesNo
If the answer is yes, briefly describe the abuse, giving specific dates.
Are you claiming the other party has been physically abusive to your children?

YesNo
If the answer is yes, briefly describe the abuse, giving specific dates.
Have any complaints been filed against the other party in this case?

YesNo
If the answer is yes, when was the complaint filed?
Date
What agency?
Marriages
Are you currently married?

YesNo
Who are you currently married to?
How many times have you been married?
For each marriage, indicate the date of marriage, if it has been dissolved, and any children from the marriage. For any prior marriage, also indicate that spouse's name.
Do you have a significant other who has been introduced to your child?

YesNo
What is that significant other's name?
Do you have any stepchildren?

YesNo

If yes, for each of your stepchildren who live with you most of the time please write down the following information:

	Child’s Name	Date of Birth	Child’s other Parent	How often is this child in your home?	Number of Children From This Marriage
Child 1
Child 2
Child 3
Child 4
Child 5

If yes, for each of your stepchildren who do not live with you most of the time please write down the following information:

	Child’s Name	Child’s other Parent	How often is this child in your home?	Number of Children From This Marriage
Child 1
Child 2
Child 3
Child 4
Child 5

Do you share your home with anyone other than your child?

YesNo

If the answer is yes please provide more specific information as to each person that you live with:

	Full Name	Age	What is their relationship to you?	What room does that person sleep in? If a room is shared, with whom?
Your name
Your child
Person 3
Person 4
Person 5
Person 6

Charges
Have you ever been charged with a crime? (A felony or misdemeanor. Do not include parking citations.)

YesNo
If the answer is Yes; state the charge (or penal code section). Include the county and court in which the proceedings were held, the case name, the case number, and the final case outcome.
To your knowledge has any parent of any of your child ever been charged with a crime? (A felony or misdemeanor. Do not include parking citations.)

YesNo
If the answer is Yes; state the charge (or penal code section). Include the county and court in which the proceedings were held, the case name, the case number, and the final case outcome.
Have you ever filed, or been subject to, a domestic violence restraining order (including someone other that the parent of this child)?

YesNo
Has the other parent of your child ever filed, or been subject to, a domestic violence restraining order (including with someone other that yourself)?

YesNo
If yes, Are these restraining orders currently in effect?

YesNo
Please give details regarding the case name, case number, name of any third party involved, and whether a restraining order after hearing was granted, and if so, give the date issued, and when it expires. Also, indicate if any TROs were ever granted, and when and when they expired?
Have you ever been physically hurt by a person whom you were living with or whom you were dating?

YesNo
If the answer is yes, please briefly describe when this occurred, and describe what occurred.
If the answer is yes, were any of your children present when you were physically hurt?

YesNo
If the answer is yes, please briefly describe whether or not your child received counseling after this incident.
Other Questions
Have you ever been treated by a mental health professional

YesNo
If yes, after you have talked with your lawyer, please advise if you are willing to waive your patient/ therapist privilege so that I may inquire as to the nature of the problem which led you to seek assistance, and the nature of the treatment you received.

YesNo
Are there members of your child(ren)’s extended families with whom your child(ren) have a particularly close relationship, such as grandparent, aunt, uncle, cousin, etc. (You should include members of the other parents family with whom your child(ren) enjoy such a relationship.)
Are there persons other than relatives of your children with whom your children have a relationship that is important to your children?

YesNo
If the answer is yes please provide each person’s name, address, and telephonic number and a brief statement of why you think this person has a special relationship with your children.
In the space write down in detail the parenting plan you feel would best serve your child(ren)’s needs and a brief statement as to why. Include any areas of dispute between you and your child(ren)’s other parent, including medical treatment, counseling, schools the children should attend, etc.
Explain any concern regarding the other parent and regarding yourself (e.g. abuse, violence, alcohol or drugs, parental alienation, irresponsibility, medical or educational issues, etc.)
THANK YOU FOR YOUR COOPERATION

I declare under penalty of perjury that the information provided herein is true and correct. I acknowledge that Minor's Counsel will rely on the statements and representations made in this questionnaire.
Date

MonthDayYear
Date
(Parent/Guardian) Signature

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Minor's Counsel - Parent Questionnaire

General Information

Work History

Additional Personal Details

Claims

Marriages

Charges

Other Questions

THANK YOU FOR YOUR COOPERATION