Request for Inclusion on the Parenting Coordinator List Name: _____________________________________ Firm Name: ________________________________ Address: ___________________________________ Office Phone: _______________________________ Address: ____________________________________ Office Fax: _________________________________ Wake County Mailbox # _______________________ Cellular Phone: _____________________________ Email: __________________________________________________________________ THIS SECTION MUST BE COMPLETED FOR INCLUSION I certify the following: (Check all that apply) I hold a masters or doctorate degree in psychology, law, social work, counseling, medicine, or a related subject area. Degree (specify in which area): ____________________________________ University/College: _____________________________________________________ Year Obtained: _________________________________________________________ I have at least five years of related professional post-degree experience. I hold a current license in my area of practice. Area of Practice: _______________________________________________________________ License Number: _______________________________________________________________ Not Applicable (list why): _________________________________________________________ I have attached a copy of my current resume or curriculum vitae. I have completed 24 hours of training in topics related to the developmental stages of children, the dynamics of high-conflict families, the stages and effects of divorce, problem solving techniques, mediation, and legal issues. I have attached documentation that clearly indicates that the above 24 hours of training requirement has been satisfied (e.g. list the trainings, dates, hours, and locations). I agree to attend parenting coordinator seminars that provide continuing education, group discussion, and peer review and support. I understand, that per HB Section 50-93, I must attend parenting coordinator seminars that provide continuing education, group discussion, and peer review and support to remain eligible to serve as a Parenting Coordinator. I will keep the Family Court Office informed of any changes in my contact information. I will contact the Family Court Office if I become ineligible to continue to serve as a Parenting Coordinator. I understand that the Chief District Court Judge will remove my name from the Parenting Coordinator List if I become ineligible to continue to serve as Parenting Coordinator. This _______ day of ________________ , 20____. ____________________________________________ Signature WAKE-DOM-25 (06/09) (Page 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com COMPLETION OF THIS SECTION IS VOLUNTARY Responding to this section will in no way impact your inclusion on the Parenting Coordinator List. Additionally, the information in this section will be kept confidential for use by the Family Court judges and staff only. It is the Parenting Coordinator’s responsibility to advise the Family Court Administrator via e-mail or facsimile of any changes in his/her rate information. Hourly Rate: $ ____________________ /hr Retainer Rate: $ ___________________ /parent Refundable? yes / no For use by the District Court Judges’ Office Only: Request for Inclusion on the Parenting Coordinator List Approved Denied: ____________________________________________ Chief District Court Judge (or designee) Date: _____________________________ WAKE-DOM-25 (06/09) (Page 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com