Information About Child

Information About Child

Kirk A. Kolodji, Esq., Kolodji Family Law PC 35 N. Lake Avenue, Suite 710, Pasadena, CA 91101 310-691-9671 | kirk@kolodjifamilylaw.com | www.kolodjifamilylaw.com
Please answer each question about your child as completely as possible. Please submit a separate Information About Child form for each child. If you do not know an answer to a question, please indicate that you do not know. If someone else can provide the information, please tell us that person’s name, relationship to the child, address, and telephone number so that we can get the information requested.
General Information
Submitted by (Party Name)

First NameLast Name
Case Name
Case Number
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
School Attendance
Does the child attend school or pre-school?

YesNo
If the answer is yes, please provide the following:
Name of School
Address of School

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number for School
Please enter a valid phone number.
Your child’s current grade level at the present time, or for the next school year (if submitted in summer break)
Teacher’s name(s) for current school year
Teacher’s name(s) for previous school year
List all the schools that your child has been to in the last three years
On what schedule does your child attend school?

Year-roundTraditional Schedule
If your child is on a year-round schedule, please provide us with the original school schedule which clearly shows the colored tracks your school district follows.
We will need copies of your child’s report cards for the last two years. Will you upload those copies with this questionnaire? (Upload files below)

YesNo
File Upload

Cancelof
What hours does your child attend school? Include the time your child arrives at school and the time your child leaves school.

Write ALL activities your child participates in through the school or in the community.

	Description of the Activity	Days of the week	Hours	During which months?
Activity 1
Activity 2
Activity 3
Activity 4
Activity 5
Activity 6

Write out the normal school start time, and end time of school, for each school day. Also include normal start-times and end-times for scheduled weekend activities.

	Start Time	End Time	Who currently does drop-offs? (Include back-ups in parenthesis)	Who currently does pick-ups?(Include back-ups in parenthesis)
Monday
Tuesday
Wednesday
Thursdays
Fridays
Weekend activities

Day Care Providers
Do you have a regular daycare provider for this child?

YesNo
If the answer is yes, please provide the following:
Name of daycare provider
Licensed?

YesNoI don't know
Address where daycare takes place

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone number
Please enter a valid phone number.
When does the child go to daycare?

Before schoolAfter schoolBoth
Is the daycare provider related to the child?

YesNo
If the answer is yes, how is the daycare provider related to the child?
How much do you pay for this daycare provider? If paid by another person, indicate who pays in parentheses.
Have you provided this daycare provider information to the other parent?

YesNo
If yes, when? If no, why not?
Medical
Provider
Primary Doctor

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Dates of most recent visits
Have you provided this medical provider information to the other parent?

YesNo
If yes, when? If no, why not?
Mental Health Provider
Provider
(If different from your medical provider)
Primary Doctor

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Dates of most recent visits
Does the child see this mental health provider regularly?

YesNo
Have you provided this mental health provider information to the other parent?

YesNo
If yes, when? If no, why not?
Dentist
Provider
Primary Dentist

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Dates of most recent visits
Reason(s) of most recent visit(s)
Does the child go to the dentist at least once every 6 months?

YesNo
Have you provided this dentist information to the other parent?

YesNo
If yes, when? If no, why not?
Eye Doctor
Provider
Primary Doctor

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Dates of most recent visit
Reason(s) of most recent visit
Does the child go regularly for routine eye exams?

YesNo
Have you provided this eye doctor information to the other parent?

YesNo
If yes, when? If no, why not?
Background
Please provide a description of your home including sleeping arrangements
Feel free to also attach a few pictures of just the sleeping arrangements.

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What is the current custodial order/parenting plan?
What would you like the custodial order/parenting plan to be?
Child's Birth History and Personality
Describe Delivery
Describe other parent’s involvement in the pregnancy and the birth.
Describe your involvement in the pregnancy and the birth.
What type of infant is/was the child.
Describe child's current personality.
Describe your child's relationship with peers. Who are your child's friends?
Describe your involvement in your child's schoolwork.
What is/are your child's favorite academic subjects?
What is/are your child's least favorite academic subjects?
What academic subjects is your child excelling in?
What academic subjects is your child struggling in?
What plan of action have, or would you like to have implemented, to maintain or improve your child's academic achievement?
Describe any concerns regarding your child's medical, psychological or educational needs.
What do you believe the court can do to help your child?
Please briefly describe any special needs of your child, and any action plan in place to address your child's special needs.
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, which may be used in Court.
Date

MonthDayYear
Date
(Parent/Guardian) Signature

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Printed Name

First NameLast Name
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Information About Child

General Information

School Attendance

Day Care Providers

Medical

Mental Health Provider

Dentist

Eye Doctor

Background

Child's Birth History and Personality

THANK YOU FOR YOUR COOPERATION