Getting to Know You and Your Family - Google Forms › wzukusers › user... · Getting to Know You and Your Family ... Let's get to know your children. 31. Please check the boxes

Getting to Know You and Your Family Click on Video

Basic information about you and your family

1. Person filling out form:

2. Date of birth

3. Address

4. Cell Phone:

5. Home Phone:

6. Employer:

7. Employer Address:

8. Occupation:

9. Level of Education:Mark only one oval.

High School

Bachelors

Masters or Doctorate

10. ExSpouse Name:

11. Address:

12. Cell Phone:

13. Date filed for Divorce:

Example: December 15, 2012

14. Court Case Number:

15. Name of Respondent:

16. Name of Petitioner:

17. Court ordered:Check all that apply.

Special Master / Parent Planning Coordinator

Reunification Therapy

Child Therapy

Binuclear Family Therapy

Parent Education

Other:

18. Date of above Court order:

Example: December 15, 2012

19. Attorney for Respondent:

20. Attorney's Address, Phone and Email:

21. Attorney for Petitioner:

22. Attorney's Address, Phone and Email:

23. Child's Attorney:

24. Child's Attorney's Address, Phone and Email:

25. Presiding Judge and Courtroom #:

26. Court Address and County:

27. Children's Names, Date of Birth and Ages :(associated with exspouse)

28. Current Custody ArrangementCheck all that apply.

Mother Sole Legal and Physical

Father Sole Legal and Physical

Joint Physical and Legal

Joint Legal, Mother Physical Custody, Father Visitation

Joint Legal, Father Physical Custody, Mother Visitation

Father's Visitation Supervised

Mother's Visitation Supervised

Supervision by Family/Friend

Supervision by Program

Supervision by Law Enforcement

29. Describe Visitation Schedule

Most important things you want from our work together.

30. What are 3 hopes/goals that you want to get from our work together?

Let's get to know your children.

31. Please check the boxes that most fit your children (prior to divorce). Child #1:Check all that apply.

Happy

Irritable

Depressed

Loving

Shy

Oppositional

Anxious

Selfish

Attention seeker

Mean spirited

Obsessive and or Compulsive

Somatic (body) concerns


Happy

Irritable

Depressed

Loving

Shy

Oppositional

Anxious

Selfish

Attention seeker

Mean spirited




Happy

Irritable

Depressed

Loving

Shy

Oppositional

Anxious

Selfish

Attention seeker

Mean spirited




Happy

Irritable

Depressed

Loving

Shy

Oppositional

Anxious

Selfish

Attention seeker

Mean spirited



35. Are there any problems at school for child #1?Check all that apply.

Perfectionistic

Good Grades

Inconsistent Grades

Poor Grades

Attention Deficit

Learning Disabilities

Significant Homework Struggles

Procrastinates and/or Appears Lazy

School Performance Anxiety

Frequently Doesn't Want to Go to School

36. Are there any problems at school for child #2 ?Check all that apply.

Perfectionistic

Good Grades

Inconsistent Grades

Poor Grades

Attention Deficit






37. Are there any problems at school for child #3 ?Check all that apply.

Perfectionistic

Good Grades

Inconsistent Grades

Poor Grades

Attention Deficit






38. Are there any problems at school for child #4 ?

Check all that apply.

Perfectionistic

Good Grades

Inconsistent Grades

Poor Grades

Attention Deficit






39. Have any of the following occurred at school?


Teacher Parent Meeting Due to Concerns

504 Plan

Student Study Team Meeting

Psychoeducational Testing (by school)

Psychoeducational Testing (privately)

IEP Plan

Would like a plan in place

40. For Which Child?

The good times with your kids

41. Describe something you really enjoy doing with child #1




45. What characteristics of your children are most irritating for you ?Check all that apply.

Not listening

Arguing/ Bossy

Doddling

Clingy Extrareliant on you

Defiant

Poor Communicator

Shy

Damage Property

Attention Seeking

Vengeful

They Give Up

Withdraw

OverUse of Electronics

46. How do you typically respond or discipline your children?Check all that apply.

Remind, Coax, Give Warnings

Time outs / Removal of Priveleges

Scream or Put Downs

Talk it out

Spanking

Give more chores

Focus on good behaviors

Show a lack of faith in them

Overhelp

Take it personally

Frequently give in

When your child struggles or acts out, what do you feel like?

47. Check all that apply.

Annoyed

Worried

Guilty

Authority is challenged

Defeated/ Wanting to give up

Wish to retaliate or get even

Hurt / dissapointed

Disbelieving / disgusted

Despair, hopeless

Helpless, inadequate

Other:

48. How would you like to better respond to your childCheck all that apply.

More patience

Offer them more support and confidence

Be calmer, less angry

Show less annoyance

Hold the rules better, be firm and kind

Show more expression of love

Stop comparing them to others

Lessen my expectations of them

Have more faith in them

Develop more routines and helpful structure

Acknowledge their feelings more

Develop mutual respect

Don't give up on them

Encourage their strengths

Engage them in problem solving

A challenge: Try to put resentments aside for a moment... Ok

now, let's go back and look at the beginning of your

marital/partner relationship.Visualize the 1st time you met your spouse, the time you felt most connected....now fill out the following....

49. Name at least 5 characteristics that attracted you to your partnerCheck all that apply.

Kind, Sweet

Giving

Shy

Smart

Understanding

Successful

Assertive

Confident

Good with kids

Athletic, Energetic, Took care of their body

Good moral person

Friendly, Outgoing

Good looks, chemistry

Engaging, good communicator

Calming, supportive

Sexy, sexual

Other:

Now let's look at the ugly, the ending of your relationship.

50. Describe a typical fight in your marriage: My ex would say/do/not do:

51. I would then feel/say/do/not do:

52. Then we would end up:Check all that apply.

Fight verbally with no resolve

Fight verbally with eventual resolve

I would withdraw

Partner would withdraw

I would turn to drinking/pills/other substances to escape

Partner would turn to drinking/pills/other substances to escape

Talk it out with satisfactory resolve

Partner would become defensive with no satisfying resolve

Other

53. Check the issues that closely resemble the reasons for divorce.Mark only one oval per row.

By Partner

Infidelity

Chronic fighting

Boring, emotionally withdrawn,

gone

Excessive drinking / substances

Financial problems

Emotionally nonunderstanding

Demanding, nagging,

overwhelming

Untreated mental health issue

Physical fighting

Controlling

Threatening (describe below)

Verbal/Emotional abuse

54. Check the issues that closely resemble the reasons for divorce.Mark only one oval per row.

By Self

Infidelity

Chronic fighting

Boring, emotionally withdrawn,

gone

Excessive drinking / substances

Financial problems

Emotionally nonunderstanding

Demanding, nagging,

overwhelming

Untreated mental health issue

Physical fighting

Controlling

Threatening (describe below)

Verbal/Emotional abuse

55. Further Description:

Briefly describe your own parents marriage

56. Did they stay marriedMark only one oval.

Yes relatively happy

Yes unhappily

No Divorced

Other:

57. Check off characteristics that best describe your parents (figures most influential inyour life)Mark only one oval per row.

Mother Figure

Caring

Helpful

Dependent

Smart

Controlling

Verbal Fighting

Abusive or Neglectful

Nagging

Alcohol or Drug Abuse

Anxious

Depressed

58. Check off characteristics that best describe your parents (figures most influential inyour life)Mark only one oval per row.

Father Figure

Caring

Helpful

Dependent

Smart

Controlling

Verbal Fighting

Abusive or Neglectful

Nagging

Alcohol or Drug Abuse

Anxious

Depressed

59. Describe their marriageCheck all that apply.

Solid and mostly happy

Not much intimacy, more roommates

Waves of verbal fighting and coming back together

Lots of criticizm and judgementalness

Domestic Violence

Infidelity

Abuse of Alcohol or Substances

I'd like you to imagine that you are a kind knowledgablechild centered judge, as the judge what would you do/order

for your children?

60. I want this Judge to: (please describe)

61. As this judge, you would order what Custody Arrangement


50/50

Ex to have visitation every other weekend

Ex to have more than every other weekend but less than 50/50

Ex to have no visitation

Ex to have supervised or limited visitation

How have the children been doing during this divorce

process?

62. Overall how are they doing? (Child #1)Mark only one oval per row.

Child #1

Don't appear to be any differentSome changes in negativedirectionClearly hurting or sufferingSome relief & positive experienceUsed to it and doing alright

63. Overall how are they doing? (Child #2)Mark only one oval per row.

Child #2

Don't appear to be any differentSome changes in negativedirectionClearly hurting or sufferingSome relief & positive experienceUsed to it and doing alright

64. Overall how are they doing? (Child #3)

Mark only one oval per row.

Child #3

Don't appear to be any different

Some changes in negative

direction

Clearly hurting or suffering

Some relief & positive experience

Used to it and doing alright

65. Overall how are they doing? (Child #4)


Child #4

Don't appear to be any different

Some changes in negative

direction

Clearly hurting or suffering

Some relief & positive experience

Used to it and doing alright

66. If they are struggling, what are you most worried about for them?


Child #1

School grades

School behavior

Home behavior

Rule compliance

Anxiety

Sadness

Anger

Withdrawal

Irritability

67. If they are struggling, what are you most worried about for them?


Child #2

School grades

School behavior

Home behavior

Rule compliance

Anxiety

Sadness

Anger

Withdrawal

Irritability

68. If they are struggling, what are you most worried about for them?Mark only one oval per row.

Child #3

School gradesSchool behaviorHome behaviorRule complianceAnxietySadnessAngerWithdrawalIrritability

69. If they are struggling, what are you most worried about for them?Mark only one oval per row.

Child #4

School gradesSchool behaviorHome behaviorRule complianceAnxietySadnessAngerWithdrawalIrritability

Any unfortunate tragedys during your children's life

(besides divorce)?

70. Check all that apply.

Deaths

Physical Illness

Sexual Abuse

Physcial Abuse

Witness to Domestic Violence

Witness to parental substance abuse

Other:

71. Describe the above further:

How is your child's health?

72. Mark only one oval per row.

Child #1

GoodOne or two issues of concernPoor (Explain)


Child #2



Child #3



Child #4


76. Describe further:

How about you? How have you been during this divorce

process?

77. On average, how is your level of anxiety?Mark only one oval.

1 2 3 4 5

Not there Horrible

78. On average, how depressed are you?Mark only one oval.

1 2 3 4 5

Fine, not

depressed

Depressed with suicidal

thoughts

79. On average, how angry are you?Mark only one oval.

1 2 3 4 5

Not

angry

Furious, consumes my thoughts

frequently

80. Have you increased or turned more to alcohol or other substances since the divorceprocess?Mark only one oval.

1 2 3 4 5

No Yes, a lot

81. Do you have support through a therapist?Check all that apply.

Yes

No

In the past, yes

Seeing a psychiatrist for medication

Other:

82. If any, what medications are you currentlytaking?

83. Who is your therapist? (name, address, phone, email and fax)

84. Who prescribes the above medications (name, address, phone, email, fax)

Prior to divorce, how were you doing?

85. Mark only one oval.

1 2 3 4 5

Well, no major issues Suffering

Any health issues for you?

86. Mark only one oval.

Good

One or two issues

Poor

Other:

Now, let's get to know you as a parent.Involvement

87. How loving and expressive are you with your kids

Mark only one oval.

1 2 3 4 5

Not at all Very

88. How involved are you in your children's school/homework?

Mark only one oval.

1 2 3 4 5

Not at all Very Involved

89. How involved are you in your children's extracurricular activities?

Mark only one oval.

1 2 3 4 5


90. How involved are you in your children's religious education?

Mark only one oval.

1 2 3 4 5


91. Choose words that describe your parenting style


Flexible

Negotiater

Parents should always have the power

Children should always respect their parents

Fair limit setting

Spanking, grabbing, pinching

Screamer

Commanding respect

Teach through modeling

Other:

92. Please list the top 3 values you have tried to instill in your children:

Based on the current custody arrangements, how is the coparenting working?

93. Overall, how is the coparenting going?Mark only one oval.

1 2 3 4 5

Amicable, it's workingok

Horrific, destructive, nonexistant

94. Generally do you think your coparent loves his/her children?Mark only one oval.

1 2 3 4 5

Not at all Absolutely

95. Check off areas of concerns you may have re: your partner


Saying negative comments about me to the kids

Manipulating them into thinking I am the "bad guy"

Frequently interrupts my time with the kids via phone/text etc.

Does not send school/health information to me in a timely fashion

Does not spend quality time with the kids

Poor parenting

Abusive with kids

Does not follow courts orders regarding drop off/pick up times

Does not use the allotted visitation time

Contacts me too frequently

Contact with me is adversarial frequently

Lying to me

Lying to children

Mediocre parenting

Involves a new partner inappropriately

Other:

96. What terms best fit for your coparenting relationshipMark only one oval per row.

Husband

Hostile/Antagonistic

Friendly/Respectful

Civil

Fluctuates Civil to Game Play

Manipulative

Cold/Distant

97. What terms best fit for your coparenting relationshipMark only one oval per row.

Wife

Hostile/Antagonistic

Friendly/Respectful

Civil

Fluctuates Civil to Game Play

Manipulative

Cold/Distant

Lets look at your child's daily and holiday commitments andsupport by coparent.

98. Overall, are the kids getting to their commitments on time and being supported by coparent?Mark only one oval.

1 2 3 4 5

Much of the time, going

well

Many problems, little

support

99. How are holidays, special occasions, vacations handled by coparent?Mark only one oval.

1 2 3 4 5

Goes pretty well Huge fighting and struggles

Powered by

100. Check all issues you wish to address:Check all that apply.

Who pays for what

Health Decisions

School Decisions

Extracurricular Decisions

Transfer/Sharing of Information

Pick up/Drop off Exchange

Parenting Style

Discipline Type

Step/Partner Involvement

Mental Health Issues

Addiction Issues

Abuse

Parent Allienation

BREATHE, Stand back and look at the bottom line... What do

you want most for your children?

101.

Copyright 2016 Creative Custody SolutionsAll Rights Reserved

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Getting to Know You and Your Family - Google Forms › wzukusers › user... · Getting to Know You and Your Family ... Let's get to know your children. 31. Please check the boxes