REFERENCE QUESTIONNAIRE CASE NAME:________________________________________ CASE NO:______________________ Name of parent/guardian for whom you are completing the questionnaire: ________________________________ INSTRUCTIONS: As you answer each question, please keep in mind that it is the responsibility of the court to safeguard the welfare and future development of the children in this family. You can help the court in meeting this responsibility by being objective and confining your statements to observations which you personally have made. Answer each question as completely as possible, using additional paper if needed. The family counselor assigned to this case may contact you personally to discuss your statement with you. Please complete the form as soon as possible. Do not give this form to the parent. Return the form to: OAKLAND COUNTY FRIEND OF THE COURT P.O. BOX 436012, PONTIAC, MI 48343-6012 Your Name ________________________________ Phone Number: Home ( )____________________________ Area Code Include Area Code Your Address_______________________________ Number Street ______________________________ City State Zip Code Your relationship to the parent/guardian above (friend, relative, employer):____________________________________________________________ How long have you known the parent/guardian above?__________________________________________________ How often do you see him/her?_______________________________________Date last seen:__________________ How long have you known the children in this case?____________________________________________________ How often do you see them?__________________________________________Date last seen:__________________ Do you know the other parent?______Yes _______No If yes, for how long?________________________________ ******************** PHYSICAL ENVIRONMENT ­ Please describe the home of the parent/guardian for whom you are a reference, including the housekeeping standards, who prepares meals, etc. Work ( )____________________________ Area Code Include Area Code v CARE OF CHILDREN ­ Describe how the parent/guardian for whom you are a reference treats the child(ren), including attention to cleanliness, clothing, discipline, supervision. PLEASE COMPLETE BACK OF FORM American LegalNet, Inc. www.FormsWorkFlow.com RELATIONSHIP TO CHILDREN ­ Describe the relationship between the parent/guardian for whom you are a reference and each child. How do they get along and what do they do together? Have you ever witnessed physical or emotional abuse of the child(ren) by either parent/guardian? Explain and give details. CHILDREN ­ State your personal observations of each child, including any physical or emotional problems known to you. PARENTS ­ To your knowledge, does either of the parents/guardians have problems in any of the following areas? Please check your response. Abuse of Alcohol_________Abuse of Drugs/Narcotics____________Criminal Involvement___________ If the answer to any of the above is yes, please give details. CUSTODY ­ If custody is an issue, please state which parent you believe should have custody and explain why based on your observations. Do you believe the other parent is unfit to have custody?____________Yes_____________No If the answer is yes, explain why. VISITATION ­ If visitation is an issue, please use your observations and knowledge to describe the type of visitation program that is in the best interests of the children and explain why. CHILDREN'S FEELINGS ­ Has the child(ren) expressed feelings and custody or visitation to you? Please give details. FOR ADDITIONAL COMMENTS, PLEASE ATTACH PAPER. THANK YOU. SIGNATURE______________________________ FC-14 (8/08) DATE______________________________ American LegalNet, Inc. www.FormsWorkFlow.com