GAL Parent / Legal Guardian Intake Questionnaire

GAL Parent / Legal Guardian Intake Questionnaire

Complete this Virginia Guardian ad Litem intake questionnaire accurately as a parent or legal guardian; your responses help the investigation and do not create an attorney-client relationship.
Optional Voluntary Authorization
I voluntarily authorize the release to the guardian ad litem for the minor child(ren) of the records or information identified below, to the extent permitted by law. This authorization is voluntary and may be revoked in writing, except to the extent action has already been taken in reliance on it.
Each item you select below is an operative grant of consent.
Which records or permissions do you voluntarily authorize?

Other
Voluntary Authorization Signature
Voluntary Authorization Printed Name

First NameLast Name
Voluntary Authorization Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Information Supplement
List any documents, photos, or other records you would like to provide to the GAL, such as medical records, school communications, or text messages.
Trial Exhibits
Exhibit 1 Description
Why is Exhibit 1 relevant?
List any additional exhibits, providing a description and relevance for each.
Witnesses
Witness 1 Full Name

First NameLast Name
Witness 1 Relationship to Child or Role
Witness 1 Phone or Email
What would Witness 1 know or say?
List any additional witnesses, including name, relationship, contact information, and expected testimony.
Submit the completed Jotform by the deadline provided by the GAL, contact the GAL's office to schedule any requested meeting, and retain a copy of the submission confirmation.
Section 1: Parent/Guardian Information
Full Name [parent_name]

First NameMiddle NameLast NameSuffix
Relationship to Child(ren) [relationship_to_child]
Preferred method of contact [contact_preference]

Other
Phone Number [parent_phone]
Please enter a valid phone number.Format: (000) 000-0000.
Email Address [parent_email]
example@example.com
Home Address [parent_address]

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Section 2: Child(ren) Information
Please list the names, birthdates, and current schools of all children for whom you are the parent or legal guardian. [children_info]
Do any of the children have special needs, medical conditions, or require accommodations? [children_special_needs]
If yes, please describe the needs/conditions/accommodations. [children_special_needs_explanation]
Section 3: Household Information
List all adults currently residing in your household (name, relationship to child, age, occupation). [household_adults]
Do you anticipate any changes in your household in the next 6 months? [household_changes]
If yes, please explain. [household_changes_explanation]
Section 4: Legal and Case Information
Are you currently involved in any other court cases concerning the child(ren)? [other_cases]
If yes, please describe the nature of the case(s) and the court(s) involved. [other_cases_explanation]
Has there been any prior involvement with Child Protective Services (CPS) regarding the child(ren)? [cps_involvement]
If yes, please explain the circumstances and outcome. [cps_involvement_explanation]
Section 5: Collateral Contacts
Please list any professionals (teachers, counselors, doctors, etc.) who have regular contact with your child(ren). [collateral_contacts]
Section 6: Additional Information
Is there any other information you believe would be helpful for the Guardian ad Litem to know? [additional_info]
Current Matter Details
Case Name or Caption
Case Number
Court
Trial or Hearing Date, if scheduled

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name(s) of the Child or Children Involved
Guardian ad Litem Name
Name of the Person Receiving/Completing This Questionnaire
Child's Wishes / Observations
What has the child said about where the child wants to live?
What has the child said about visits or contact?
Describe the child's relationship with siblings and other children in either household.
What changes have you observed in the child's mood, sleep, appetite, school performance, or behavior?
Has the child made any concerning statements or disclosures to you? If yes, state what was said and when.
Extended Family / Collateral Witnesses
Witness 1
Collateral-source types

Other
Relief Requested
What do you want the court to do?
Check all that apply

Other
Describe your proposed parenting or placement plan.
Documents You Have Now
Check all that apply

Other
Closing Questions
What do you think the court most needs to know about this child?
What do you think the court most needs to know about you?
What records or witnesses support your position?
Collateral Person 1 Full Name

First NameLast Name
Collateral Person 1 Relationship or Role
Collateral Person 1 Phone or Email
Collateral Person 1 Why this person is relevant
Collateral Person 2 Full Name

First NameLast Name
Collateral Person 2 Relationship or Role
Collateral Person 2 Phone or Email
Collateral Person 2 Why this person is relevant
Collateral Person 3 Full Name

First NameLast Name
Collateral Person 3 Relationship or Role
Collateral Person 3 Phone or Email
Collateral Person 3 Why this person is relevant
What records or witnesses may contradict your position?
Section 5A: Caregiving History
Describe your role in the child's daily life.
Check all tasks you usually handle
Has the child ever lived apart from you?
If yes, when and why?
Have you ever withheld the child from the other parent or caregiver?
If yes, explain.
Has the other parent or caregiver withheld the child from you?
If yes, explain.
Who cares for the child while you are working or otherwise unavailable?
Describe the child's transitions before and after visits.
What is your discipline approach?
Section 5B: Child Health / Development / Mental Health
Primary care provider.
Dentist.
Therapist or counselor.
Psychiatrist or psychologist.
Other specialists.
Does the child have any diagnosed condition?
If yes, explain.
Current medications.
Allergies.
Check all that apply
Explain any checked item.
Who currently consents to medical or mental health treatment?
Section 5C: Education
Attendance concerns?
If yes, explain.
Academic concerns?
If yes, explain.
Behavior or discipline concerns at school?
If yes, explain.
Bullying or peer issues?
If yes, explain.
Is transportation to school reliable?
Who communicates with the school?
Extracurricular activities.
Section 5D: Parent / Guardian Functioning
Employment status
Employer.
Work schedule.
Do you have reliable transportation?
Do you have any physical condition affecting caregiving?
If yes, explain.
Do you have any mental health condition affecting caregiving?
If yes, explain.
Any current treatment or medication relevant to caregiving?
If yes, explain.
Any substance use history relevant to caregiving or child safety?
If yes, explain.
Are you willing to submit to voluntary drug or alcohol screening if requested?
Are you an active-duty, reserve, or National Guard member of the military?
If yes, note any upcoming deployment, training, or relocation.
Do you plan to move in the next 12 months?
If yes, where and why?
Who helps you with the child in emergencies?
Section 5E: Criminal / Protective Order / Abuse-Neglect History
Have you ever been arrested?
Have you ever been charged with a criminal offense?
Have you ever been convicted?
Is any criminal case pending now?
Do you have any probation, parole, or bond conditions?
Any incarceration history?
Has any protective order been entered against you or in your favor?
Any abuse or neglect finding involving any child?
Any prior child removal or termination-of-parental-rights proceeding involving any child?
If yes to any of the preceding questions, explain fully, including court, charge or allegation, date, and disposition.
Are you aware of any such history for any adult in your household?
If yes, identify the adult and explain.
Section 5F: Relationship with Other Parent / Caregiver
Current relationship category
How do you currently communicate?
Can you communicate about the child safely?
Can exchanges occur safely?
What are the main disputes?
Do you support the child having a relationship with the other parent or caregiver if safe?
If no, explain.
Do you believe supervision is necessary?
If yes, by whom and why?
Section 1A: Expanded Parent/Guardian Identifying Information
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other names used, maiden name, or aliases
Mailing Address (if different from Home Address)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Best days and times to reach you
Are you represented by an attorney in this matter?
Attorney Name
Firm
Attorney Phone
Please enter a valid phone number.Format: (000) 000-0000.
Attorney Email
example@example.com
Do you need any accommodation to participate in this matter?
If yes, please explain the accommodation needed
Do you need an interpreter or translated documents?
If yes, please state the language
Please provide a recent picture of the child or children. You may send the picture separately to the GAL.
Section 1B: Legal Status / Parental Role
Are you the child's biological parent?
Do you claim legal custody rights?
Do you claim physical custody rights?
Are you a court-appointed guardian?
Are you acting in loco parentis?
If applicable, describe your legal status and any relevant orders
Section 2A: Expanded Household Composition
Current address where the child stays with you (if different from Home Address)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How long have you lived there? (Years)
How long have you lived there? (Months)
Type of housing
Is the housing stable?
For each adult already listed above, provide date of birth, whether the person lives there full-time, and whether the person has overnight contact with the child
Other adults who regularly care for or supervise the child: name, date of birth, address, phone, and email
Does the child have a separate sleeping space?
If no, please explain
Any home safety concerns?
If yes, please explain the home safety concerns
Are there firearms or weapons in the home?
If yes, please describe how they are stored
Any pets creating safety concerns?
I certify that, to the best of my knowledge, the information I have provided is true and complete. I understand that the guardian ad litem represents the interests of the minor child(ren), not me personally. I understand that my completion of this form does not create an attorney-client relationship between me and the guardian ad litem. I understand that I may supplement or correct my answers in writing.
Please list and briefly describe each pet, including name and type
Section 2B: Expanded Child Information
Add structured entries for up to six children. For each child, include full name, date of birth, school or daycare, and current grade; if a child primarily lives somewhere else, include that address
If a child primarily lives somewhere else, does that apply here?
Address where the child primarily lives (if different from your address).

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Who currently has physical custody?
Who currently has legal custody?
Describe the current visitation or contact arrangement
Is the current arrangement working?
If no, please explain why
Section 3: Immediate Safety Screen
Are you aware of any immediate safety concern involving the child?
If yes, please explain the safety concern
Check all that apply

Other
Has the child ever been injured while in your care or the other parent's/caregiver's care?
If yes, please explain the injury
Has the child witnessed violence, arrests, overdoses, or other traumatic events?
If yes, please explain
Does the child fear any person or place?
If yes, please explain
Is there a current safety plan?
If yes, state who created it and what it requires
Section 4: Expanded Court / Agency Involvement
Check all that apply

Other
For each case or investigation, provide the Court or Agency, Case Number, Type of Case, Status, and Next Court Date
Are there any founded or pending DSS/CPS findings?
Child 1 Full Name

First NameLast Name
Child 1 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 1 School or Daycare
Child 1 Current Grade
Child 2 Full Name

First NameLast Name
Child 2 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 2 School or Daycare
Child 2 Current Grade
Child 3 Full Name

First NameLast Name
Child 3 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 3 School or Daycare
Child 3 Current Grade
Child 4 Full Name

First NameLast Name
Child 4 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 4 School or Daycare
Child 4 Current Grade
Child 5 Full Name

First NameLast Name
Child 5 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 5 School or Daycare
Child 5 Current Grade
Child 6 Full Name

First NameLast Name
Child 6 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child 6 School or Daycare
Child 6 Current Grade
If yes, please explain
Section 7: Review and Certification
By signing below, I certify that the information provided is complete and accurate to the best of my knowledge. [certification]
Signature [signature]
Printed Name [signature_printed_name]

First NameLast Name
Date [signature_date]

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

GAL Parent / Legal Guardian Intake Questionnaire

Optional Voluntary Authorization

Additional Information Supplement

Trial Exhibits

Witnesses

Section 1: Parent/Guardian Information

Section 2: Child(ren) Information

Section 3: Household Information

Section 4: Legal and Case Information

Section 5: Collateral Contacts

Section 6: Additional Information

Current Matter Details

Child's Wishes / Observations

Extended Family / Collateral Witnesses

Relief Requested

Documents You Have Now

Closing Questions

Section 5A: Caregiving History

Section 5B: Child Health / Development / Mental Health

Section 5C: Education

Section 5D: Parent / Guardian Functioning

Section 5E: Criminal / Protective Order / Abuse-Neglect History

Section 5F: Relationship with Other Parent / Caregiver

Section 1A: Expanded Parent/Guardian Identifying Information

Section 1B: Legal Status / Parental Role

Section 2A: Expanded Household Composition

Section 2B: Expanded Child Information

Section 3: Immediate Safety Screen

Section 4: Expanded Court / Agency Involvement

Section 7: Review and Certification