2HomeKids Inquiry

2HOME KIDS PROGRAM

Red * indicates a response is required.

Which Hannah's House service are you signing up for?

Name

First NameLast Name

Are you the Custodial or Non-custodial Parent?

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Alternative Phone Number

Area CodePhone Number

Email

example@example.com

Other Party's Name

First NameLast Name

Other Party's Phone Number

Area CodePhone Number

Other Party's Email

example@example.com

Who Referred You?

Per the Court Order, who has LEGAL custody?

Have you used Hannah's House services before? When?

Children

Please provide the ALL children's full name (as they appear in court order documentation), their dates of birth and the sex of each child.

How long has it been since the children had contact with the Non-Custodial parent? are there phone or skype calls?

Why is supervised visitation recommended in this situation?

For example: due to a Restraining Order, due to child abuse, mental illness, etc.

How many hours per week are ordered?

For example: due to a Restraining Order, due to child abuse, mental illness, etc.

Has there been a previous order for supervised visitation?

If so, where did you receive services and the dates of services.

Next Court Date?

Date

Next Mediation Date?

Date

Is there any risk of flight/abduction on the part of either parent?

Are there any Restraining Orders in effect?

Is there a history or current concern about Domestic Violence?

Is there a history or current concern about Child Abuse (physical or sexual)?

Is there a history or current concern about Alcohol or Drug Abuse?

If YES to above question, please indicate what type of alcohol or drug abuse.

Is there an order for alcohol or drug assessment/testing?

Please indicate if there are any legal issues pending that are related to the case.

Indicate "NA" if no legal issues pending.

Have you heard about out Transitions Family Program (psycho-educational & clinical services)?

I understand I will receive acknowledgement of receipt of this screening form within 48 hours and I will then be scheduled for a required new-client orientation. I also understand Hannah's House will start working on contacting the other party to also get them started on the intake process, if they have not already done so.

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