Minor's Counsel

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
Case Name
Case Number
Your Name

First NameLast Name
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.
Additional Personal Details
Date of Birth

MonthDayYear
Date
Driver's License Number
State
Social Security Number
What is the highest grade level in school/ degree you have completed?
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
How many times have you been married?

If you have been married more than once, fill out the table.

	Name of Spouse	Dates of Marriage	How was the Marriage Terminated?	County and State of Divorce	Number of Children From This Marriage
Marriage 1
Marriage 2
Marriage 3
Marriage 4

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

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

Charges
Have you ever been charged with a crime? (Do not include parking citations that did not require you to go to court)

YesNo
If the answer is Yes; on a separate piece of paper give us details about the crime. Include the county and court in which the proceedings were held, the case name, the case number, and the reason for the proceeding, including the final outcome. If you have paperwork for this case, please provide us with copies.
To your knowledge has any parent of any of your children ever been charged with a crime? (Do not include parking citations that did not require you to go to court)

YesNo
If the answer is Yes; on a separate piece of paper give us the name of the person who was charged with this crime and give us details about the crime. Include the county and court in which the proceedings were held, the case name, the case number, and the reason for the proceeding, including the final outcome. If you have paperwork for this case, please provide us with copies.
Have you ever filed for or been subject to domestic violence restraining orders?

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

YesNo
If you answered yes to either of those questions, on a separate sheet of paper give us details regarding why these restraining orders were issued. Include the county and court in which the proceedings were held, the case name, case number, and the reason for the restraining order, including the dates the orders was issued, or what the outcome resulted. If you have paperwork for this case, please provide us with copies.
Have you ever been treated for injuries sustained as a result of being assaulted by a person whom you were living with or whom you were dating?

YesNo
If the answer is yes, were any of your children present during the assault?

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 the answer is yes, after you have talked with your lawyer, please let us know if you are willing to waive your patient/ therapist privilege so that we may inquire as to the nature of the problem which led you to seek assistance and the nature of the treatment you received.
Do you share your home with anyone other than your children?

YesNo

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

	Name	Age	How this person is related to you?	How long?
Child 1
Child 2
3
Child 4

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

Powered by Jotform SignClear
Should be Empty:

Minor's Counsel - Parent Questionnaire

General Information

Work History

Additional Personal Details

Claims

Marriages

Charges

Other Questions

THANK YOU FOR YOUR COOPERATION