Lic. No. PSY 6296
VOICE/FAX
(805) 650-9232
GARY R. RICK, Ph.D.
CLINICAL AND FORENSIC PSYCHOLOGY
grickphd@pacbell.net
SUITE 107
950 COUNTY SQUARE DRIVE
VENTURA, CALIFORNIA 93003-5454
Four documents are attached to this form: Please complete the questionnaire including specifying collateral
persons you think can provide me with information helping me understand the interests of the child or children
in this case.
Secondly, there is a release form for professionals such as therapists and physicians with whom you or your
child have a confidential relationship. Please complete and sign the form including telephone and fax numbers.
Thirdly, there is a form for teachers, school administrators, school psychologists, and other educators.
Finally, there is a form for community members including family, neighbors, friends, and others who may have
information about the interests of the child or children in the case. They will be contacted by phone in most
cases. Please do not discuss the case with these persons, but you may tell them to expect a call from me.
You must sign the two release forms. Either mail them to me or send them as email attachments with scanned
in signatures. Thank you.
IMPORTANT: The questionnaire is 11 pages long. Please give short focused responses and
DO NOT EXCEED 20 PAGES ON THE QUESTIONNAIRE.
DO NOT EXCEED 4 PAGES ON THE TIMELINE.
If there are any questions, please contact me. Thank you.
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GARY R. RICK, Ph.D.
Your Name:_____________________________
674 COUNTY SQUARE DRIVE, STE 307
VENTURA, CALIFORNIA 93003-5454
(805) 650-9232
Home Phone:_____________________________
Work Phone:_____________________________
CASE
NAME:_____________________________________________
Cell:___________________________________
CASE
NUMBER:___________________________________________
E-mail:_________________________________
Birthdate: ________________Age:____________
CHILD CUSTODY QUESTIONNAIRE
(This information is NOT CONFIDENTIAL)
A.
IDENTIFYING DATA
DATE:______________________
Full Name (current): _________________________________________________
Marital Status (current): ___________________________________________________
Place of Birth: ______________________________________
Religion in which Raised: __________________________________________________
Religion (current): ________________________________________________________
Your Home Address: _____________________________________________________
List Occupants of Your Home: ______________________________________________
_______________________________________________________________________
_______________________________________________________________________
LIST NAMES OF ANY PERSON WITH CUSTODIAL RESPONSIBLITIES (Childcare person or facility,
babysitter, family member, friend, etc.)
Name and Facility
Phone and Fax Numbers
Relationship
B.
EMPLOYMENT
Name of Employer:
Address of Employer:
2
Occupation:
How long employed:
Work Hours:
Gross Income for last calendar year: $__________________Present Year/$________________
Previous Job Positions:
Employer
C.
Your Position
Dates
CHILDREN:
Name
Birthday
Living With
School Attending
a. When in your care, what are the child care arrangements:
3
b. Give description of home, including sleeping arrangements:
c. How does the child(ren) get to school and back home:
d. What is the current Court Order/Custody Plan and date of Order (be specific):
e. What have been the custody and visitation arrangements since the separation (be specific as to dates and
circumstances):
f. What custody plan do you think is best:
g. Explain why:
4
D.
ISSUES OF CONCERN:
1.
Summarize from your perspective the major aspects of the current situation, including concerns you
have in regard to your self or your former spouse/parent of the children at issue; e.g., sexual abuse, domestic
violence, drug or alcohol abuse, romances, irresponsibility, medical or educational issues, etc.:
2.
Summarize form your perspective how you think the other parent would describe the major aspects of
the current situation, including concerns in regard to yourself or your former spouse/parent of the children at
issue, e.g. sexual abuse, domestic violence, drug or alcohol abuse, romances, irresponsibility, medical or
educational issues, etc.:
5
E.
CHILDREN’S DATA:
List the names and ages of the child or children and briefly describe their personality traits, interests, and any
concerns you have about them.
Describe school history for each child (performance, social adjustments, grade level, etc.): (ATTACH
CURRENT REPORT CARD)
F.
MARITAL HISTORY
List all marriages:
Name
Date of
Marriage
Date of Separation
Date of Divorce
No. of Children
1ST
2ND
3RD
4TH
Are you contemplating marriage now:
YES_______
NO________
If yes, please give name:
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G.
MARITAL INFORMATION OF SPOUSE/PARENT OF CHILD(REN) AT ISSUE:
1. Where/how did you meet:
2. Date you began living together:
3. Date and place you married (if married):
4. Describe other parent’s parenting of child(ren):
5. Date and circumstances of separation from other parent:
Is your divorce final: YES_____________
NO_______________
If yes, give date:
H.
FAMILY OF ORIGIN (father, mother, brothers, sisters)
1. Where were you born and raised:
2. How Long were your parents married:
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3. Are your parents divorced:
If yes, how old were you at the time:
4. Did your parents remarry: (Be specific as possible, how old were you, etc.)
5. Who raised you:
6. Father (describe his occupation & your relationship):
7. Mother (describe her occupation & your relationship):
\
8. Siblings (give name, age, and relationship with your brothers/sisters):
9. Have you ever had a problem with Alcohol? If so describe fully.
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10. Would anyone allege that you have a current drinking problem?
11. Describe your current frequency and quantity of alcohol consumption.
12. Have you ever had a problem with illegal drugs? If so describe fully.
13. Would anyone allege that you have a drug problem?
14. Describe your current frequency and quantity of any marijuana or other drug consumption
15. Criminal history (all arrests and convictions, including DUI arrests and convictions in self and/or family
members:
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16. Litigation history (describe all lawsuits in which your were either a plaintiff or respondent:
I.
PERSONAL DATA (please be specific and give past and present information):
1. Education:
2. Medical History:
3. Prescribed medication:
4. Psychiatric treatment/ Psychotherapy and/ or Counseling:
5. Psychiatric Hospitalization history:
J.
STEPPARENT OR DOMESTIC PARTNER INFORMATION:
If you have remarried or if you now share or plan to share your home with another adult or if there is a
significant other person in your life, please complete the following questions in regard to this person:
1. Name:
2. Age:
Date of Birth:
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3. Place of birth:
4. Present employer/position:
5. Marital history: (Including birth dates and ages of children from former marriages/relationships):
Name of Spouse
Date of Marriage
Date of Divorce
No. Children
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. Describe your relationship with current spouse/domestic partner/significant other:
7. Describe relationship between your current spouse/domestic partner/significant other and the child(ren) at
issue:
8. Was there ever any type of domestic violence in your marriage/relationship with the other parent? If so
please describe:
9. List your residence addresses during the last ten years and inclusive dates.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________
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Time Line
Please prepare a timeline of critical events during and after the marriage. Provide a brief description of
important occurrences in chronological order on a separate sheet of paper. Please be concise but complete.
Below is a professionally created timeline. Please use it as an example. Please give basic facts only.
Timeline
9/31/92
Sally Mother and Joe Father marry in Detroit, MI. Move to Newbury Park after honeymoon in Florida.
10/6/93
Birth of Child. Father not present because of work.
1998
Marriage doing well after therapy with Dr. Smith. Both parents stop drinking.
3-23-99
Mother moves out of home and files for a temporary restraining order.
Declaration of mother, 3-25-99
Declaration of father, 3-29-99
3/28/ 99
Father moves to home of parents with visitations facilitated by paternal grandmother on alternate weekends.
4/22/2000
Mother cited for driving without a license.
Police report # 22223
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GARY R. RICK, Ph.D.
Lic. No. PSY 6296
CLINICAL AND FORENSIC PSYCHOLOGY
VOICE/FAX
(805) 650-9232
grickphd@pacbell.net
SUITE 307
674 COUNTY SQUARE DRIVE
VENTURA, CALIFORNIA 93003-5454
REQUEST
TREATING PROFESSIONALS
FOR AND AUTHORIZATION TO RELEASE RECORDS AND INFORMATION
I hereby authorize Dr. Gary Rick, Ph.D., as well as the individuals listed below, to release and receive
protected health and any other oral and/or written information regarding signatories of this form
and/or the minor child(ren) listed below. I understand that this information may either help or hinder
my case.
__________________________________________________________________________
Name of Child or Party in Case
Phone Number
Name
Fax/Email
Relationship
__________________________________ _______________________ ______________________ _________________________
__________________________________ _______________________ ______________________ _________________________
__________________________________ _______________________ ______________________ _________________________
__________________________________ _______________________ ______________________ _________________________
__________________________________ _______________________ ______________________ _________________________
__________________________________ _______________________ ______________________ _________________________
I fully understand this Authorization and Release and the consequences and implications of the release, and
my request is wholly voluntary on my part. I understand that records may be sent via facsimile to unintended
parties because of clerical or electronic error. I hereby release the source of this information from any liability
arising from its release. I authorize the parties above to talk by telephone or in person about my referral,
diagnoses, treatment, and similar topics relevant to the assessment, treatment or other process being pursued.
I understand that provision of services is not contingent upon this releasing of records. I understand that I may
revoke this consent at any time except to the extent that action based on this consent has been taken. This
consent will expire automatically after one year from the date on which it is signed.

Signature
Printed Name
Date
Signature
Printed Name e
Date
A photocopy or facsimile of this authorization shall be considered valid.
C-P
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GARY R. RICK, Ph.D.
Lic. No. PSY 6296
CLINICAL AND FORENSIC PSYCHOLOGY
VOICE/FAX
(805) 650-9232
grickphd@pacbell.net
SUITE 307
674 COUNTY SQUARE DRIVE
VENTURA, CALIFORNIA 93003-5454
Educational Professionals
AUTHORIZATION TO RELEASE EDUCATIONAL AND RELATED INFORMATION
LIST CURRENT AND FORMER SCHOOLS OF MINOR CHILDREN
Teacher- School Address
Phone and Fax Nos.
Child
Dates
REQUEST FOR AND AUTHORIZATION TO RELEASE RECORDS AND INFORMATION
I hereby authorize Dr. Gary Rick, as well as the individuals listed above, to release and receive oral
and/or written information regarding signatories of this form and/or the minor child(ren) listed below. I
understand that this information may either help or hinder my case.
__________________________________________________________________________
( child’s full name)
I fully understand this Authorization and Release and the consequences and implications of the release, and my request
is wholly voluntary on my part. I understand that records may be sent via facsimile to unintended parties because of
clerical or electronic error. I hereby release the source of this information from any liability arising from its release. I
authorize the parties above to talk by telephone or in person about my referral, diagnoses, treatment, and similar topics
relevant to the assessment, treatment or other process being pursued. I understand that provision of services is not
contingent upon this releasing of records. I understand that I may revoke this consent at any time except to the extent that
action based on this consent has been taken. This consent will expire automatically after one year from the date on which
it is signed.
Signature
Printed Name
Date
Signature
Printed Name
Date
A photocopy or facsimile of this authorization shall be considered valid.(C-E)
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Community Member Master List
YOUR NAME____________________________
LIST THE NAMES OF COLLATERAL PERSONS WHO MIGHT PROVIDE MEANINGFUL
INFORMATION IN AN INTERVIEW ON THE TELEPHONE OR OFFICE. PLEASE LIST ONLY
PERSONS WHO HAVE POTENTIALLY MEANINGFUL INFORMATION.
Name
Phone Numbers
Relationship
(C-2)
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