PARENTING REFERENCE QUESTIONNAIRE

North Texas Family Services, PLLC

Lauren Gordon, LCSW

Mailing address:

8301 Lakeview Parkway Suite 111-131, Rowlett TX 75088

By Appointment Only:

2607 Lee Street, Greenville, TX

email address: laurengordon@ntxfamilyservices.com

phone: 214.675.3978
You are being asked to participate in a child custody evaluation. The purpose of the evaluation is to make recommendations to the court when parents cannot agree on the best parenting plan for their child or children. Your participation is voluntary. Your responses are not confidential - they may be shared with the court, the attorneys, and the parties involved in this suit. You may be called and asked additional questions about your responses. Please do not return your response to the parent who asked you to complete this questionnaire.

Please answer the following questions as completely and objectively as possible.
Date Completed*

MonthDayYear
Date
Full name of the person who asked you to complete this questionnaire*

First NameLast Name
Your name:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The questions below will pertain to the parent who has asked you to complete this form:
What is your relationship with this parent?*
How long have you known them:*
How often do you have contact with them? *
When was the last time you had contact with them?*
Do you know the children in this case? How often do you see them?*
Based on your observations of this parent, and their child(ren), describe their strengths and weaknesses. *
Have you ever had any concerns about this parent related to emotional stability, substance use, anger, or other topics that may impact a person’s ability to parent? If so, describe. *
The following questions will be answered for the other parent in this case:

IF YOU DO NOT KNOW THIS PARENT STOP HERE
What is your relationship with the other parent? How long have you known them? How often do you have contact with them? When was the last contact?
Based on your observations of the other parent and their child(ren), describe their strengths and weaknesses as a parent.
How often have you seen the other parent and the child or children together? Based on those observations, how would you describe their relationship?
Have you ever had any concerns about the other parent related to emotional stability, substance use, anger or other topics that may impact a persons ability to parent? If so, describe.
Any additional observations or information that you believe an evaluator should know, please complete here:
Date*

MonthDayYear
Date
I affirm I have completed this form and these are my opinions solely based on my experiences with the family. *

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The questions below will pertain to the parent who has asked you to complete this form:

The following questions will be answered for the other parent in this case: