CD, Section VI: Parent Questionnaire
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SECTION
VI
Parent Questionnaire
The purpose and reasons for using a Parent Questionnaire are explained in
Chapter 12. Let me say again that this questionnaire is not a psychological test,
because there are no scores or norms involved, and no attempt to establish reliability
or validity. The questionnaire is simply a more organized, written way to collect
information.
To adapt the Parent Questionnaire for your practice, substitute your information
for the information in brackets at the end of the questionnaire.1
The Parent Questionnaire – Child Custody Evaluation reproduced in this CD is an edited, re-formatted version of a
Guardian ad Litem – Evaluation Questionnaire developed by Linda Santos Smith, Ph.D., from an earlier questionnaire by
Joseph Onofrio, LICSW. My revised version of the questionnaire is reprinted here with the permission of Dr. Smith and
Mr. Onofrio.
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1
CD, Section VI: Parent Questionnaire
Parent Questionnaire, Page 1
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Name of Person completing questionnaire:____________________________
PARENT QUESTIONNAIRE – CHILD CUSTODY EVALUATION
The purpose of this questionnaire is to assist me as the child custody evaluator appointed in your child custody
matter. Truthful and complete answers will help me conduct a more comprehensive evaluation in the most efficient and
cost-effective manner possible. The information that you provide will be combined with additional information gathered
throughout the evaluation process, and then all of the available information will be used to formulate my recommendations
to the Court.
It is important to understand that any information obtained by a child custody evaluator is not privileged or
confidential and will likely be reported to the Court. In turn, the Court may disseminate that information to the other
parties, individuals, or professionals associated with your child custody evaluator matter.
While completing this questionnaire, please print clearly in black ink. Please answer to the best of your ability.
Some of the questions may not apply to you or your family; for those questions, please write “N/A” (not applicable). If you
prefer not to answer a question, please make a note of that on the form – do not leave any questions blank. If you need
more space, use the back of the form. Once completed, please sign and date the last page and remember to mail the
questionnaire to me at least a week before your next appointment.
Case Name:_________________________________Court:__________________________Docket #:_______________
Current Attorney’s Name:___________________________Attorney’s Phone:_______________Fax:________________
Address:________________________________________________Email:______________________________
Names of your previous attorneys in this case:_________________________________________________________
__________________________________________________________________________________________
Your Personal Information
First Name:__________________________Middle:____________________Last:________________________________
Maiden Name:________________________Other Name(s) you have been known by:____________________________
Date of Birth:_____________Place of Birth:_________________________________Social Security No:______________
Citizenship Status:_____________________Race:______________________Ethnic Background___________________
Religion:_________________________Currently active? What activities?______________________________________
Your Relationship to the Child(ren) in the case (e.g. mother, stepfather, adoptive, etc)_____________________________
Current Marital/Coupled Status:________________________When did relationship begin?________________________
Date of marriage:_____________Date of Separation:______________Date of Divorce:_____________________
Previous Marriages: Date of Marriage:_________________Separation:________________Divorce:_________________
Date of Marriage:_________________Separation:________________Divorce:_________________
Previous long-term relationships:______________________________________________________________________
Current Address:___________________________________________________How long have you lived there?_______
Previous Address:__________________________________________________How long did you live there?_________
Current Contact Information for you:
Home Phone:__________________ Cell Phone:_________________________
Work Phone:__________________ Fax:_______________. Email:________________________________ ___
Who Lives (or frequently stays over) at your home?________________________________________________________
CD, Section VI: Parent Questionnaire
Parent Questionnaire, Page 2
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Name of Person completing questionnaire:____________________________________________
Are there any weapons in your home?_____If yes, what?___________________Where and how stored?_____________
Have you ever been issued a permit/license to own/possess a firearm or other type of weapon?______________
If yes, when and where?______________________________________________________________________
Do you own or have access to a legally registered motor vehicle? ______Describe vehicle_________________________
Your Parents (Please provide information even if deceased.)
Mother: Name:_________________________________Birthdate:_____________If deceased, at what age?______
Occupation:__________________________________Current marital status:_____________________________
Number of marriages:_________Address::________________________________________________________
Telephone:___________ Any major health problems in your childhood?________________________________
Father: Name:_________________________________Birthdate:_____________If deceased, at what age?______
Occupation:__________________________________Current marital status:_____________________________
Number of marriages:_________Address::________________________________________________________
Telephone:___________ Any major health problems in your childhood?________________________________
Your Siblings
Sibling #!: Name:_____________________________Age:____ Relationship (brother, stepsister, etc.)_______________
Address:___________________________________________________________Telephone:_____________
Occupation:___________________________________________Marital status:________________________
How many children?_______________Major health problems?______________________________________
Additional information_______________________________________________________________________
Sibling #2: Name:_____________________________Age:____ Relationship (brother, stepsister, etc.)_______________
Address:___________________________________________________________Telephone:_____________
Occupation:___________________________________________Marital status:________________________
How many children?_______________Major health problems?______________________________________
Additional information_______________________________________________________________________
CD, Section VI: Parent Questionnaire
Parent Questionnaire, Page 3
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Name of Person completing questionnaire:____________________________________________
Sibling #3: Name:_____________________________Age:____ Relationship (brother, stepsister, etc.)_______________
Address:___________________________________________________________Telephone:_____________
Occupation:___________________________________________Marital status:________________________
How many children?_______________Major health problems?______________________________________
Additional information_______________________________________________________________________
Your Educational History
Elementary School:_______________________________________City/State:__________________________________
Grades Attended:__________________________________Dates Attended:_____________________________
Middle School:___________________________________________City/State:__________________________________
Grades Attended:__________________________________Dates Attended:_____________________________
High School:____________________________________________City/State:__________________________________
Grades Attended:__________________________________Dates Attended:_____________________________
Did you graduate high school?________________________If so, when?:________________________________
If not, what is highest grade completed?___________Did you earn a GED? ________When?________________
College/Technical School and Degree(s)earned:____________________________________________Date:__________
Please indicate any additional training/education:__________________________________________________________
Do you have any learning disabilities? If yes, explain:______________________________________________________
Did you receive any special education services? If yes, provide details:________________________________________
__________________________________________________________________________________________
Your Employment and Military History
Are you currently employed_________If so, where?_______________________________________________________
Dates of employment:________________What is your position there?__________________________________
Describe duties:_____________________________________________________________________________
What is your current work schedule?_____________________________________________________________
Briefly list previous employment history:_________________________________________________________________
__________________________________________________________________________________________
Do you hold any professional licences/certificates?________________________________________________________
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Name of Person completing questionnaire:____________________________________________
Were you ever in the military?___________If so, what branch?_______________________________________________
Rank:_______________________Where were you stationed?________________________________________
Describe duties:_____________________________________________________________________________
Dates of service:____________________________Discharge status:___________________________________
Additional information:________________________________________________________________________
Your Current Financial Situation
Income: Gross annual income (before taxes):___________________________________________________________
Your spouse/partner’s gross annual income (before taxes):_________________________________________
Assets: Your approximate total assets:________________________________________________________________
Your approximate total debt:__________________________________________________________________
Do you have any financial concerns?___________________________________________________________________
Who primarily handled the finances while you were married/coupled?__________________________________________
Your Medical History
Do you have medical insurance?________ If yes, name of insurance company:_________________________________
Who is your primary care doctor?___________________________________ Date of last routine physical exam:_______
Contact information for doctor:__________________________________________________________________
How many pregnancies have you had?_____________How many children have you given birth to?__________________
Do you use tobacco?_______________How much daily?___________________________________________________
Do you drink alcohol?_____How often do you drink?______________How much do you drink each time?_____________
Do you use any other substances (including “recreational drugs,” prescription or over-the-counter medications, etc)?____
If yes, what type(s)?__________________________________________________________________________
How often?___________________ How much do you use?___________________________________________
Have you been diagnosed or treated for any chronic/recurrent medical conditions?______ If yes, which ones?_________
_________________________________________________________________________________________
Have you been diagnosed or treated for any behavioral issues, substance abuse, or mental illnesses?______
If yes, which ones?__________________________________________________________________________
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Name of Person completing questionnaire:____________________________________________
Please list any medications you are currently prescribed. (Include name of medication, dosage, and reason prescribed.)
__________________________________________________________________________________________
Please list any previous hospitalizations. (Include date, hospital, and reason for hospitalization.)_____________________
__________________________________________________________________________________________
Your Family’s Medical History
Please indicate which family members (parents, siblings, aunts & uncles, grandparents) have had any of the following:
Diabetes______________________________ Death at an early age__________________________________
Positive TB test_________________________ Stomach/Intestinal problems_____________________________
High blood pressure_____________________ Asthma/Respiratory problems____________________________
Blood disease/Anemia____________________ Psychiatric Problems__________________________________
Heart Attack____________________________ Substance Abuse/Alcoholism____________________________
Kidney Problems________________________ Epilepsy/Seizures_____________________________________
Mental Retardation_______________________ Trauma____________________________________________
Cancer________________________________ Birth Defects_________________________________________
Anxiety/Depression ______________________ Anger Problems______________________________________
Stroke_ _______________________________ Family/Domestic Violence______________________________
Other__________________________________ Other_______________________________________________
Your History of Therapy and Social Support Services
Please indicate below if you have ever used any services such as individual therapy, couples therapy, or group therapy;
Alcoholics Anonymous, Narcotics Anonymous, or Al-anon; psychiatrist; domestic violence services; and state agencies
such as Departments of Transitional Assistance, Mental Health, or Mental Retardation.
Have you every been in therapy?_____ If yes, what type? (Individual, marital/couples, family, other)?_________________
(Please give details below for each therapy, in addition to other services you have used.)
Provider #1: Name:_________________________________Agency/Program:__________________________________
Address:_________________________________________________________Phone:____________________
Type of Services received:______________________________________Time period: ____________________
How often (weekly, semi-weekly, etc.):___________________________________________________________
Did you find it helpful?________ How/Why?_______________________________________________________
CD, Section VI: Parent Questionnaire
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Name of Person completing questionnaire:____________________________________________
Provider #2: Name:_________________________________Agency/Program:__________________________________
Address:_________________________________________________________Phone:____________________
Type of Services received:______________________________________Time period: ____________________
How often (weekly, semi-weekly, etc.):___________________________________________________________
Did you find it helpful?________ How/Why?_______________________________________________________
Provider #3 Name:_________________________________Agency/Program:__________________________________
Address:_________________________________________________________Phone:____________________
Type of Services received:______________________________________Time period: ____________________
How often (weekly, semi-weekly, etc.):___________________________________________________________
Did you find it helpful?________ How/Why?_______________________________________________________
Provider #4 Name:_________________________________Agency/Program:__________________________________
Address:_________________________________________________________Phone:____________________
Type of Services received:______________________________________Time period: ____________________
How often (weekly, semi-weekly, etc.):___________________________________________________________
Did you find it helpful?________ How/Why?_______________________________________________________
Any additional information about the problems or services listed above:________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Your History of Legal Involvement and Child Protective Services
Legal Involvement
Have you ever been involved in a civil suit?_______ If yes, please indicate date(s), court(s), and circumstances________
__________________________________________________________________________________________
Have you ever been involved in a Restraining Order?_______ If yes, explain:___________________________________
__________________________________________________________________________________________
Have the police ever been to your home?________ If yes, please indicate date(s), location(s), and circumstances_______
__________________________________________________________________________________________
__________________________________________________________________________________________
CD, Section VI: Parent Questionnaire
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Name of Person completing questionnaire:____________________________________________
Have you ever been arrested?______ If yes, please indicate date(s), location(s), and circumstances_________________
__________________________________________________________________________________________
Do you have a criminal record in this or any other state?_____ If yes, please explain_____________________________
__________________________________________________________________________________________
Have you ever been on probation? ____ If yes, when and through what courts?_________________________________
Who was your probation officer?______________________________________Telephone:_________________
What were the conditions of your probation?_______________________________________________________
Have you ever been incarcerated?____ If yes, please indicate date(s), location(s), and circumstances_______________
__________________________________________________________________________________________
Mediation
Have you every participated in mediation?_______ If yes, reason for mediation?________________________________
How many sessions?_____ What was the resolution, if any?__________________________________________
Child Protective Services
Have you (as an adult) or your children ever been involved with the Mass. Dept. of Social Services (DSS) or its equivalent
in another state?_____ If yes, please indicate date(s), location(s), and circumstances_____________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Who is/was your social worker?_______________________________________ Telephone:________________
Have you or your children ever been involved in a Care and Protection or Child in Need of Services (CHINS) matter, or
a similar matter in another state?_____ If yes, please indicate date(s), court(s), and circumstances:_________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Any additional information:___________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
CD, Section VI: Parent Questionnaire
Parent Questionnaire, Page 8
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Name of Person completing questionnaire:____________________________________________
Your Children
Child #1:
Name (first, middle, last):_________________________________________________Date of birth:___________
Place of birth:__________________________________________________
Race:_____________________
Ethnicity:________________________ Religion_____________________________________________
Who is the biological mother?_____________________________________________ Date of birth:___________
Who is the biological father?______________________________________________ Date of birth:___________
Were the parents married at the time of birth?__________ Is biological father named on birth certificate?_______
Where does the child live?_____________________________________________________________________
Who has physical custody of the child?________________Who has legal custody of the child?_______________
During the pregnancy/birth:
Did the mother use tobacco?___Alcohol?_____ Medication?__________Other substances?:__________
Any complications during pregnancy or birth?________________________________________________
Any concerns about child’s health after birth?________________________________________________
Medical history:
Is child covered by medical insurance?_____ Name of insurance co.____________________________
Pediatrician:_____________________________________________________ Telephone:___________
Date of last medical visit?__________ When was last routine physical?____________________
Is the child up-to-date with routine visits and immunizations?_____________________________
Dentist:_________________________________________________________Telephone:____________
Date of last dental visit:_________________Date of last routine check-up:__________________
Other medical providers or specialists who treat your child:_____________________________________
_____________________________________________________________________________
Has the child experienced any of the following medical problems?
Ear infections:_____ Asthma:_____ Heart Murmur:_____ Eczema:_____ Allergies:__________
Any significant medical concerns?_________________________________________________________
School/daycare:
Facility name:________________________ Address:________________________________________
Contact person:______________________________________ Telephone:_______________________
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Name of Person completing questionnaire:____________________________________________
How well does the child do in school? ________ Any developmental delays or learning disabilities?____
_____________________________________________________________________________
Does the child have an individualized education plan (IEP)?______ What accommodations does the
child require?__________________________________________________________________
Does the child have any behavioral problems at home, in school, or in the community?_____________________
___________________________________________________________________________________
What services does the child receive?_____________________________________________________
What are the child’s favorite activities?___________________________________________________________
___________________________________________________________________________________
Please describe the child:_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please describe your relationship with the child:____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Any additional information about child #1:_________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Name of Person completing questionnaire:_________________________________
Child #2:
Name (first, middle, last):_________________________________________________Date of birth:___________
Place of birth:__________________________________________________
Race:_____________________
Ethnicity:________________________ Religion_____________________________________________
Who is the biological mother?_____________________________________________ Date of birth:___________
Who is the biological father?______________________________________________ Date of birth:___________
Were the parents married at the time of birth?__________ Is biological father named on birth certificate?_______
Where does the child live?_____________________________________________________________________
Who has physical custody of the child?________________Who has legal custody of the child?_______________
During the pregnancy/birth:
Did the mother use tobacco?___Alcohol?_____ Medication?__________Other substances?:__________
Any complications during pregnancy or birth?________________________________________________
Any concerns about child’s health after birth?________________________________________________
Medical history:
Is child covered by medical insurance?_____ Name of insurance co.____________________________
Pediatrician:_____________________________________________________ Telephone:___________
Date of last medical visit?__________ When was last routine physical?____________________
Is the child up-to-date with routine visits and immunizations?_____________________________
Dentist:_________________________________________________________Telephone:____________
Date of last dental visit:_________________Date of last routine check-up:__________________
Other medical providers or specialists who treat your child:_____________________________________
_____________________________________________________________________________
Has the child experienced any of the following medical problems?
Ear infections:_____ Asthma:_____ Heart Murmur:_____ Eczema:_____ Allergies:_________
Any significant medical concerns?_________________________________________________________
School/daycare:
Facility name:________________________ Address:________________________________________
Contact person:______________________________________ Telephone:_______________________
How well does the child do in school? ________ Any developmental delays or learning disabilities?____
_____________________________________________________________________________
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Name of Person completing questionnaire:_________________________________
Does the child have an individualized education plan (IEP)?______ What accommodations does the
child require?__________________________________________________________________
Does the child have any behavioral problems at home, in school, or in the community?_____________________
___________________________________________________________________________________
What services does the child receive?_____________________________________________________
What are the child’s favorite activities?___________________________________________________________
___________________________________________________________________________________
Please describe the child:_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please describe your relationship with the child:____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Any additional information about child #2:_________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Name of Person completing questionnaire:_________________________________
Child #3:
Name (first, middle, last):_________________________________________________Date of birth:___________
Place of birth:__________________________________________________
Race:_____________________
Ethnicity:________________________ Religion_____________________________________________
Who is the biological mother?_____________________________________________ Date of birth:___________
Who is the biological father?______________________________________________ Date of birth:___________
Were the parents married at the time of birth?__________ Is biological father named on birth certificate?_______
Where does the child live?_____________________________________________________________________
Who has physical custody of the child?________________Who has legal custody of the child?_______________
During the pregnancy/birth:
Did the mother use tobacco?___Alcohol?_____ Medication?__________Other substances?:__________
Any complications during pregnancy or birth?________________________________________________
Any concerns about child’s health after birth?________________________________________________
Medical history:
Is child covered by medical insurance?_____ Name of insurance co.____________________________
Pediatrician:_____________________________________________________ Telephone:___________
Date of last medical visit?__________ When was last routine physical?____________________
Is the child up-to-date with routine visits and immunizations?_____________________________
Dentist:_________________________________________________________Telephone:____________
Date of last dental visit:_________________Date of last routine check-up:__________________
Other medical providers or specialists who treat your child:_____________________________________
_____________________________________________________________________________
Has the child experienced any of the following medical problems?
Ear infections:_____ Asthma:_____ Heart Murmur:_____ Eczema:_____ Allergies:_________
Any significant medical concerns?_________________________________________________________
School/daycare:
Facility name:________________________ Address:________________________________________
Contact person:______________________________________ Telephone:_______________________
How well does the child do in school? ________ Any developmental delays or learning disabilities?____
_____________________________________________________________________________
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Name of Person completing questionnaire:_________________________________
Does the child have an individualized education plan (IEP)?______ What accommodations does the
child require?__________________________________________________________________
Does the child have any behavioral problems at home, in school, or in the community?_____________________
___________________________________________________________________________________
What services does the child receive?_____________________________________________________
What are the child’s favorite activities?___________________________________________________________
___________________________________________________________________________________
Please describe the child:_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please describe your relationship with the child:____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Any additional information about child #3:_________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Name of Person completing questionnaire:_________________________________
Child #4:
Name (first, middle, last):_________________________________________________Date of birth:___________
Place of birth:__________________________________________________
Race:_____________________
Ethnicity:________________________ Religion_____________________________________________
Who is the biological mother?_____________________________________________ Date of birth:___________
Who is the biological father?______________________________________________ Date of birth:___________
Were the parents married at the time of birth?__________ Is biological father named on birth certificate?_______
Where does the child live?_____________________________________________________________________
Who has physical custody of the child?________________Who has legal custody of the child?_______________
During the pregnancy/birth:
Did the mother use tobacco?___Alcohol?_____ Medication?__________Other substances?:__________
Any complications during pregnancy or birth?________________________________________________
Any concerns about child’s health after birth?________________________________________________
Medical history:
Is child covered by medical insurance?_____ Name of insurance co.____________________________
Pediatrician:_____________________________________________________ Telephone:___________
Date of last medical visit?__________ When was last routine physical?____________________
Is the child up-to-date with routine visits and immunizations?_____________________________
Dentist:_________________________________________________________Telephone:____________
Date of last dental visit:_________________Date of last routine check-up:__________________
Other medical providers or specialists who treat your child:_____________________________________
_____________________________________________________________________________
Has the child experienced any of the following medical problems?
Ear infections:_____ Asthma:_____ Heart Murmur:_____ Eczema:_____ Allergies:_________
Any significant medical concerns?_________________________________________________________
School/daycare:
Facility name:________________________ Address:________________________________________
Contact person:______________________________________ Telephone:_______________________
How well does the child do in school? ________ Any developmental delays or learning disabilities?____
_____________________________________________________________________________
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Name of Person completing questionnaire:_________________________________
Does the child have an individualized education plan (IEP)?______ What accommodations does the
child require?__________________________________________________________________
Does the child have any behavioral problems at home, in school, or in the community?_____________________
___________________________________________________________________________________
What services does the child receive?_____________________________________________________
What are the child’s favorite activities?___________________________________________________________
___________________________________________________________________________________
Please describe the child:_____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please describe your relationship with the child:____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Any additional information about child #4:_________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Name of Person completing questionnaire:_________________________________
Other People for the Evaluator to Contact
Please indicate the individuals whom I should contact during the evaluation as additional sources of information.
Professionals who work or have worked with you and your children are important sources of information and should be
included (e.g. medical providers, teachers, therapists). Adult therapists and couples/family therapists are especially
useful. In addition, you can identify three other personal references (e.g. neighbor).
Please put a star beside the three people you most want me to contact. I will evaluate which sources of
information are most important for your evaluation. The amount of time (and hence cost) involved limits the number of
people I can talk with, so I may not be able to contact everyone you have listed.
Please include all relevant identifying/contact information, including name, address, telephone number, fax
number, Email address, and relationship to you or your child. Then use this information to complete and sign an
Authorization for Release of Information form for each person you list here.
Name:_____________________________________
Name:____________________________________________
Relationship to your family:_____________________
Relationship to your family:____________________________
Address:____________________________________
Address:___________________________________________
___________________________________________
__________________________________________________
Telephone Number:___________________________
Telephone Number:__________________________________
Fax Number:________________________________
Fax Number:________________________________________
Email Address:_______________________________
Email Address:______________________________________
Name:_____________________________________
Name:____________________________________________
Relationship to your family:_____________________
Relationship to your family:____________________________
Address:____________________________________
Address:___________________________________________
___________________________________________
__________________________________________________
Telephone Number:___________________________
Telephone Number:__________________________________
Fax Number:________________________________
Fax Number:________________________________________
Email Address:_______________________________
Email Address:______________________________________
Name:_____________________________________
Name:____________________________________________
Relationship to your family:_____________________
Relationship to your family:____________________________
Address:____________________________________
Address:___________________________________________
___________________________________________
__________________________________________________
Telephone Number:___________________________
Telephone Number:__________________________________
Fax Number:________________________________
Fax Number:________________________________________
Email Address:_______________________________
Email Address:______________________________________
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Name of Person completing questionnaire:_________________________________
Name:_____________________________________
Name:____________________________________________
Relationship to your family:_____________________
Relationship to your family:____________________________
Address:____________________________________
Address:___________________________________________
___________________________________________
__________________________________________________
Telephone Number:___________________________
Telephone Number:__________________________________
Fax Number:________________________________
Fax Number:________________________________________
Email Address:_______________________________
Email Address:______________________________________
Name:_____________________________________
Name:____________________________________________
Relationship to your family:_____________________
Relationship to your family:____________________________
Address:____________________________________
Address:___________________________________________
___________________________________________
__________________________________________________
Telephone Number:___________________________
Telephone Number:__________________________________
Fax Number:________________________________
Fax Number:________________________________________
Email Address:_______________________________
Email Address:______________________________________
Name:_____________________________________
Name:____________________________________________
Relationship to your family:_____________________
Relationship to your family:____________________________
Address:____________________________________
Address:___________________________________________
___________________________________________
__________________________________________________
Telephone Number:___________________________
Telephone Number:__________________________________
Fax Number:________________________________
Fax Number:________________________________________
Email Address:_______________________________
Email Address:______________________________________
CD, Section VI: Parent Questionnaire
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Name of Person completing questionnaire:_________________________________
Preferences Regarding Legal and Physical Custody of Your Children
Where would you like your child to live (physical custody)?__________________________________________________
How would you like to make decisions about your child (legal custody)? (Please choose one)
_____Jointly with the other parent (joint custody)
_____By one parent alone (sole legal custody):
_______Yourself
_____Other parent
Reasons for your preferences:________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Signature
I attest that the information in this questionnaire is true to the best of my knowledge and belief. I further understand that
any information contained herein may be used within the context of the evaluation by the child custody evaluator, will be
reported to the Court, and that the Court may make the Report of the Custody Evaluation available to individuals or
professionals associated with the legal matter.
Signed under the pains and penalties of perjury on this __________day of _____________,20______.
____________________________________________
Parent Signature
____________________________________________
Printed Name
Thank you for completing this questionnaire. I appreciate your time, information, and cooperation.
Please be sure to mail the completed questionnaire to me at least a week before your next appointment, so I will
have time to review it before we meet. Also, please bring a completed and signed Authorization for Release of
Information form for each individual that you wish me to contact. Just make photocopies of the Release form enclosed in
this packet.
If you have any additional documentation or materials you want me to review, please bring photocopies of them to
your appointment. I am required to retain a permanent file of all materials that I review for the evaluation, so please do
not give me original copies of any personal or family items you would like to have returned.
If you have any questions, please contact me. Email and telephone are the most convenient forms of
communication.
[Evaluator Name and Credential]
[Facility]
[Street Address]
[City/town, State, zip Code
Tel.: xxx-xxx-xxxx
Fax: xxx-xxx-xxxx
Email: [Evaluator Email address]