APPLICATION FOR APPROVAL FOR LISTING ON SONOMA COUNTY SUPERIOR COURT PARENT COORDINATOR PANEL ___________________________________ Name (last, first, middle initial) ___________________________________ State Bar Number or Professional License (type and number) ___________________________________ Mailing address ___________________________________ City State Zip ___________________________________ Telephone Number ___________________________________ Occupation (if not an attorney) ___________________________________ Fax/Cellular Telephone Number ___________________________________ Email Address ____________________________________________________________________________________ Please complete the following questionnaire, and provide required information as listed. 1. I have capabilities in the following languages: ______________________________________________________________________________ Explain degree of fluency: ________________________________________________________ Years of practice in Law _____________________ Counseling _______________ Other_____________________________ __________________________________ __________________________________ 2. 3. Are you a Family Law Specialist? Yes No Are you a licensed mental health counselor? Yes No If so, what is your area of practice? ______________________________________________ Have you ever acted as a Parent Coordinator under appointment of a court? Yes No If so, please state how many times, when and the nature of your assigned duties _______________ ____________________________________________________________________________________ ____________________________________________________________________________________ 4. 5. 6. Are there any disciplinary proceedings pending against you? Yes Have you been previously disciplined? Yes No No Local Form FL-037 Adopted for Mandatory Use Eff. 2/2014 APPLICATION FOR APPROVAL FOR LISTING ON SONOMA COUNTY SUPERIOR COURT PARENT COORDINATOR PANEL Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR APPROVAL FOR LISTING ON SONOMA COUNTY SUPERIOR COURT PARENT COORDINATOR PANEL If your answer to 5 and/or 6 is yes, please explain (in the alternative, you may make an appointment with the Supervising Family Law Judge to explain privately): _______________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 7. Have you attended a Parent Coordinator Training? Yes No Name of training and where (attach program if available): ______________________________________________________________________________ ______________________________________________________________________________ Attorneys or counselors seeking court approval are required to meet the following standards. Please mark the appropriate boxes: Attorney for at least ten (10) years during which time at least 70% of practice devoted to family law, with substantial emphasis in child custody cases; Counselor/mental health professional for at least ten (10) years during which 50% of practice has been devoted to counseling or mediating child custody cases; Maintain professional liability insurance to cover parent coordinator work; Completion of training/seminars/workshops sponsored by the Sonoma County Superior Court and SCBA Family Law Section or any other court-sponsored training, etc., for parent coordinator. 9. Please list other recent (within five (5) years) professional training, experience, professional affiliations which are relevant to performing parent coordinator: 8. Program title # of hours Dates # of hours completed ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Local Form FL-037 Adopted for Mandatory Use Eff. 2/2014 APPLICATION FOR APPROVAL FOR LISTING ON SONOMA COUNTY SUPERIOR COURT PARENT COORDINATOR PANEL Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR APPROVAL FOR LISTING ON SONOMA COUNTY SUPERIOR COURT PARENT COORDINATOR PANEL 10. In order to maintain eligibility for court referrals, you must agree to comply with the following if requested: a. Acknowledge requirement to maintain current license and professional liability insurance. Yes No b. Participate in minimum continuing education. c. Agree to provide itemized billing if requested by either party or Court. d. Agree to report to the Supervising Family Law Judge, in writing: a) Initiation of any disciplinary proceedings within five (5) days of actual knowledge of such proceeding, including basis of the complaint; b) The result of any such disciplinary proceeding; and c) Notice of suspension of your license. Yes Yes No No Yes No I certify that all statements made on this application for initial approval or renewal to the Family Law Parent Coordinator Panel are true and complete to the best of my knowledge. I understand that any false, incomplete or incorrect statement may result in my disqualification from the selection process. I understand that if I am approved or renewed to the Panel, I will be required to abide by all rules, regulations, and policies of the Court with respect to the Family Law Parent Coordinator Panel. I further recognize that the Court may revise these rules, regulations and policies at any time. I declare under penalty of perjury that all information I have provided is correct. ___________________________ Signature ___________________________ Date ___________________________ Print name Local Form FL-037 Adopted for Mandatory Use Eff. 2/2014 APPLICATION FOR APPROVAL FOR LISTING ON SONOMA COUNTY SUPERIOR COURT PARENT COORDINATOR PANEL Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com