Information About Child

Information About Child

Kirk A. Kolodji, Esq.Kolodji Family Law PC35 | N. Lake Avenue, Suite 710,Pasadena, CA 91101310-691-9671 | kirk@kolodjifamilylaw.com | www.kolodjifamilylaw.com
Please answer each question about your child as completely as possible. 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
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 grade level at the present time or for the next school year
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

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?
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
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
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
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
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
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.
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 the child.
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