CD, Section VIIIa: Collateral Information -- Professionals and Institutions
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SECTION
1
VIIIa
Collateral Information – Professionals and Institutions
This section contains the following forms for collecting collateral information from
professional or institutional sources.

Letter to Police Department

Letter to Department of Social Services

Letter to Pediatrician

Letter to Couples Therapist

Letter to Individual Psychotherapist or Counselor

Letter to School

Questions for Teachers

Interview for Teachers
The forms in this section are designed to standardize contacts and interviews
with professionals and the staff of various institutions. In reviewing evaluations, it is
important to ascertain whether the evaluator used a structured set of questions to
standardize the collection of both written and oral materials. Such standardization is
the best way to increase convergent validity, because it is possible to compare the
answers that different individuals gave to the same questions.
To use these forms, simply (a) remove the heading for the form, and (b) insert
the correct information for your practice in the areas indicated by brackets.
CD, Section VIIIa: Collateral Information – Professionals and Institutions
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LETTER TO POLICE DEPARTMENT
[LETTERHEAD OF CUSTODY EVALUATOR]
[Date]
Sent via fax to 000-000-0000
Records Department
Police Department
[Town, State, Zip code]
RE:
Case Name
[Name of Court]
Docket No. 000-000-0000
To Whom It Concerns:
I am a psychologist appointed by the [Name of Court] to do a child custody evaluation in
the [case name] child custody dispute. As part of my evaluation, I need to obtain the
police records for any incidents involving either [name of parent #1] or [name of parent
#2].
I am enclosing copies of the following:
 My court appointment as a custody evaluator
 Release of Information forms signed by both parents:
[name of parent #1] and [name of parent #2],
Please fax the records to me at 000-000-0000.
Thank you very much for your assistance.
Sincerely,
[Name and Credential of Evaluator]
[Evaluator Title and Facility]
Enc.
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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LETTER TO DEPARTMENT OF SOCIAL SERVICES
[LETTERHEAD OF CUSTODY EVALUATOR]
[Date]
Sent via fax to 000-000-0000
[Department of Social Services]
[Street number]
[Town, State, Zip code]
RE:
[Case Name]
[Name of Court]
Docket No. 000-000-0000
To Whom It Concerns:
I am a psychologist appointed by the [Name of Court] to do a child custody evaluation in
the [case name] child custody dispute. As part of my evaluation, I need to obtain all of
the Department of Social Service records that involve [name of parent #1] or [name of
parent #2].
I am enclosing copies of the following:
 My court appointment as a custody evaluator
 Release of Information forms signed by both parents:
[name of parent #1] and [name of parent #2],
Please fax or mail me copies of any child abuse investigations [51A and 51B reports] as
well as any case plans. In addition, if there is an on-going social worker for this family, I
would like to speak with them.
Thank you very much for your assistance.
Sincerely,
[Name and Credential of Evaluator]
[Evaluator Title and Facility]
Enc.
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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LETTER TO PEDIATRICIAN
[LETTERHEAD OF CUSTODY EVALUATOR]
[Date]
[Pediatrician Name and Credential]
[Title]
[Facility]
[Street Address]
[City/Town, State, Zip Code]
Dear Dr. [Name of Pediatrician]:
Sent via fax to 000-000-0000
RE:
[Name of Child #1]
DOB 00/00/0000
[Name of Child #2]
DOB 00/00/0000
[Name of Case]
[Name of Court]
Docket No. 00000000
I am a clinical psychologist appointed by the [Name of Court] to do a child custody
evaluation in the [Name of Case] child custody dispute. As part of my evaluation,
I need to obtain the medical records for the children named above.
I am enclosing copies of the following:
 Release of Information forms signed by both parents:
[Name of Parent #1] and [Name of Parent #2]
 My court appointment as a custody evaluator in this case
I would like to obtain information about the following:
 Children’s general health, both physical and mental
 Diagnoses for any chronic medical conditions
 Which parent usually makes appointments and brings the children to those
appointments.
 Parent’s general provision for the medical needs of the children
 Any particular concerns you may have about these children or their family.
Please fax the information requested at 000-000-0000. If you would like to speak with
me, please call me at 000-000-0000 and leave some times when I might call you back.
Thank you very much for your assistance.
Sincerely,
[Name and Credential of Evaluator]
[Title]
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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LETTER TO COUPLES THERAPIST
[LETTERHEAD OF CUSTODY EVALUATOR]
[Date]
[Therapist Name and Credential]
[Title]
[Facility]
[Street Address]
[City/Town, State, Zip Code]
Dear Dr. [Name of Therapist]:
Sent via fax to 000-000-0000
RE:
[Name of Parent #1]
DOB 00/00/0000
[Name of Parent #2]
DOB 00/00/0000
[Name of Case]
[Name of Court]
Docket No. 00000000
I am a clinical psychologist appointed by the [Name of Court] to do a child custody
evaluation in the [Name of Case] child custody dispute. As part of my evaluation,
I need to obtain the medical records for the couples therapy that you did with the
parents, [name of parent #1 and name of parent #2].
I am enclosing copies of the following:
 My court appointment as a custody evaluator in this case
 Release of Information forms signed by both parents:
[Name of Parent #1] and [Name of Parent #2]
I would like to obtain information about the following:
 General psychological functioning of each parent
 Parenting capacities of each parent.
 Family dynamics and Interaction patterns between the parents
 Any information related to patterns of common couple violence, physical abuse,
or verbal abuse between the parents or in the family as a whole.
 Any particular concerns you may have about these parents.
Please send the relevant written records, and call me at 000-000-0000 to arrange a time
when we could talk on the telephone.
Thank you very much for your assistance.
Sincerely,
[Name and Credential of Evaluator]
[Title]
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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LETTER TO INDIVIDUAL PSYCHOTHERAPIST OR COUNSELOR
[LETTERHEAD OF CUSTODY EVALUATOR]
[Date]
Sent via fax to 000-000-0000
[Therapist Name and Credential]
[Title]
[Facility]
[Street Address]
[City/Town, State, Zip Code]
RE:
[Name of Parent]
DOB: 00/00/0000
SSN: 000-00-0000
[Name of Custody Case]
[Name of Court]
Docket No. 00000000
Dear Dr. [Name of Therapist]:
I am a clinical psychologist appointed by the [Name of Court] to do a child custody
evaluation in the [Name of Case] child custody dispute. As part of my evaluation,
I need to obtain the medical records for the individual psychotherapy that you did with
[name of parent] during [approximate time period of therapy].
I am enclosing copies of the following:
 My court appointment as a custody evaluator in this case
 Release of Information forms signed by [Name of Parent]:
I would like to obtain information about the following regarding [name of parent]:
 General psychological functioning.
 Any psychiatric diagnoses
 Any psychotropic medications, including name, dosage, prescribing professional,
and reason for medication
 Dates and reasons for any hospitalizations
 Parenting capacities
 Family dynamics, if known
 Any particular concerns you may have about this patient.
Please fax the information to me at 000-000-0000, along with any intake summaries and
discharge summaries you may have. I would also like to speak with you about [parent
name]. Please call me at 000-000-0000 and leave some times when I might call you
back.
Thank you very much for your assistance.
Sincerely,
[Name and Credential of Evaluator]
[Title]
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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LETTER TO SCHOOL
[LETTERHEAD OF CUSTODY EVALUATOR]
[Date]
Sent via fax to 000-000-0000
[Name]
[Title]
[Name of School]
[Street Address]
[City/town, State, Zip Code]
RE:
[Name of Child]
DOB 00/00/0000
[Name of Case]
[Name of Court]
Docket No. 00000000
Dear [Name of Teacher, Guidance Counselor, or Principal]:
I am a psychologist appointed by the [name of court] to do a child custody evaluation in
the [name of case] child custody dispute. As part of my evaluation, I need to speak with
the [child name]’s teachers.
I am enclosing copies of the following:
 My court appointment as a child custody evaluator in this case
 Release of Information forms signed by both parents:
[Name of Parent #1] and [Name of Parents #2]
 Questions for Teachers.
I would like to speak with you or with [Child Name]’s teachers about her general social
adjustment and performance in school. The enclosed Questions for Teachers will give
you an idea of the type of information I am seeking.
Please call me at 000-000-0000 to arrange a time when we could talk on the telephone.
Thank you very much for your assistance.
Sincerely,
[Name and Credential of Evaluator]
[Title]
[Facility]
Enc.
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
Questions for Teachers
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[Evaluator Name] – page 1
CHILD CUSTODY EVALUATIONS – QUESTIONS FOR TEACHERS
These questions are not exhaustive, but should give you an idea of the type of
information that I need to obtain from the child’s school when doing a child
custody evaluation. I hope that they will be useful to you in thinking about the
child before our consultation.
Knowledge of/contact with child and family
1. How long and in what capacity have you known the child and the family?
2. Has the child worked with the Guidance Counselor or School Psychologist?
(If yes, I may need to speak with that person directly.)
Social and emotional adjustment
3. How does the child interact with other children?
4. Does the child have friends?
5. Is the child well-liked?
6. Does the child understand and participate in the group social norms?
7. Are there any indications of inappropriate aggressive or sexually oriented
behaviors?
8. Are there any difficulties with impulse control?
9. Does the child have difficulty waiting their turn, sitting still, or paying
attention in class?
10. How does the child respond to limit-setting?
11. Is the child attached to the teacher? To the school?
Attendance and Physical Appearance
12. Which parent brings the child to school? Which takes the child home?
13. How has the child’s school attendance been?
If frequently absent, what have the reasons been?
If frequently late, what have the reasons been?
14. How does the child’s physical appearance compare with that of other students?
Is the child usually dressed appropriately for the weather?
Does the child seem well-cared for?
Academic/cognitive abilities
15. How does the child’s academic performance compare to other children their
age?
16. What are the child’s academic strengths and weaknesses?
17. Does the child have any special needs?
How are these addressed in school?
Does the child have an Individual Education Plan?
18. Does the child complete their homework on time?
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
Questions for Teachers
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[Evaluator Name] – page 2
Overall Impression of Child
19. How would you describe the child’s personality style?
20. What are the child’s strengths and weaknesses?
21. Has the child ever expressed strong feelings about the divorce or custody
situation?
22. Do you have any special concerns about the child?
Family Issues
23. Does each parent make sure that the child completes their homework
assignments?
24. Does each parent provide a structured environment and support the child’s
school work at home?
25. Do the parents come to parent-teacher meetings?
26. Do the parents participate in the over-all school life (bake sales, festivals,
field trips, etc.)?
27. Do you know of any substance abuse or mental health problems in this
family?
28. Do you know of any issues of domestic violence in this family?
29. What is your overall impression of the parents?
30. Do you have any special concerns about the family?
Please call to give me a few times when I can reach you by telephone.
Thank you very much for your help.
[Name and contact information for evaluator]
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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CHILD CUSTODY EVALUATIONS – INTERVIEW FOR TEACHERS
Name of child:____________________________________________________
Grade:__________________________________________________________
School:__________________________________________________________
Teacher/Staff Member’s Name:______________________________________
Teacher/Staff Member’s Title or function:_____________________________
Teacher/Staff Member’s Title or function:_____________________________
Date and time of interview:_________________________________________
Location of interview:______________________________________________
WARNING OF LACK OF CONFIDENTIALITY GIVEN
Knowledge of/contact with child and family
1. How long and in what capacity have you known the child and the family?
2. Has the child worked with the Guidance Counselor or School Psychologist?
(If yes, I may need to speak with that person directly.)
Social and emotional adjustment
3. How does the child interact with other children?
4. Does the child have friends?
5. Is the child well-liked?
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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6. Does the child understand and participate in the group social norms?
7. Are there any indications of inappropriate aggressive or sexually oriented
behaviors?
8. Are there any difficulties with impulse control?
9. Does the child have difficulty waiting their turn, sitting still, or paying
attention in class?
10. How does the child respond to limit-setting?
11. Is the child appropriately attached to the teacher? To the school?
Attendance and Physical Appearance
12. Which parent brings the child to school? Which takes the child home?
13. How has the child’s school attendance been?
If frequently absent, what have the reasons been?
If frequently late, what have the reasons been?
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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14. How does the child’s physical appearance compare with that of other students?
Is the child usually dressed appropriately for the weather?
Does the child seem well-cared for?
Academic/cognitive abilities
15. How does the child’s academic performance compare to other children their
age?
16. What are the child’s academic strengths and weaknesses?
17. Does the child have any special needs?
How are these addressed in school?
Does the child have an Individual Education Plan?
18. Does the child complete their homework on time?
Overall Impression of Child
19. How would you describe the child’s personality style?
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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20. What are the child’s strengths and weaknesses?
21. Has the child ever expressed strong feelings about the divorce or custody
situation?
22. Do you have any special concerns about the child?
Family Issues
23. Does each parent make sure that the child completes their homework
assignments?
24. Does each parent provide a structured home environment that supports the
child’s school work?
25. Do the parents come to parent-teacher meetings?
26. Do the parents participate in the over-all school life (bake sales, festivals,
field trips, etc.)?
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CD, Section VIIIa: Collateral Information – Professionals and Institutions
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27. Do you know of any substance abuse or mental health problems in this
family?
28. Do you know of any issues of domestic violence in this family?
29. What is your overall impression of the parents?
30. Do you have any special concerns about the family?
31. Is there anything else you would like to tell me?
Evaluator:
[Name and contact information for evaluator]
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