DATE DUE TO COURT ____________ CASE NUMBER __________________ MAGISTRATE ____________________ DATE RECEIVED__________________ PARENTAL QUESTIONNAIRE AND INFORMATION SHEET The Court has referred your family for a Parental Evaluation to collect information necessary to assist the Court in reaching a decision concerning the residency of your minor child(ren). Please fill out the attached questionnaire, neatly and completely. It can be typed or hand written with black ink. It is very important that you answer all questions truthfully and accurately. Evasive and fraudulent statements WILL be taken into consideration. Fill out the questionnaire yourself, sign your name and return the form to the court address on or before the date ordered. A CRIMINAL BACKGROUND CHECK WILL THEN BE PERFORMED. Also, after the questionnaires are received, you will be contacted to schedule an appointment to meet with the Parental Specialist. A. PERSONAL: __________________________________ Case Name (last, first, middle) _____________________________________ Home Phone # Work Phone # __________________________________________________ Cellular Phone # Mailing Address _________________________________________ City State Zip _____________________________________________ SS # DOB _________________________________________ Attorney Name _____________________________________________ Attorney Phone # _____________________________________________ Attorney Mailing Address ______________________________________________ Your email Address ______________________________________________ Attorney email Address EMPLOYMENT: ______________________________________________ Business Name Business Address Position Date employed Business Phone # Hourly Rate/Salary ______________________________________________ ________________________________________________ Work Hours and Days Please circle highest grade completed (circle one) 6 7 8 9 10 11 12 College or Vocational training:_______________________________________________________ B. CHILDREN: NAMES AND ADDRESSES OF CHILDREN INVOLVED IN THIS COURT ACTION NAME DOB LIVING WITH ADDRESS _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ DR-606 1 Rev. 8/15 American LegalNet, Inc. www.FormsWorkFlow.com NAMES OF CHILDREN NOT INVOLVED IN THIS COURT (INCLUDE STEP-SIBLINGS) NAME DOB LIVING WITH ADDRESS _________________________________________________________________________________________________ _________________________________________________________________________________________________ What school does(do) the child(ren) involved in this action attend? CHILD GRADE TEACHER SCHOOL ADDRESS PHONE # _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ In what interests and leisure time activities is/are the child(ren) involved? CHILD ACTIVITIES _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ C. MARITAL HISTORY: What have been the major problems in the marriage? Were there any previous separations? Who initiated the separation? Who left the home? Have you filed for divorce before? If so, where?__________________ D. CUSTODY: Is there a Court Order for custody? Are you requesting Shared Parenting? Have you filed a Shared Parenting plan? Have you filed for custody? No No No No Yes Yes If yes, who has custody?__________________ Yes Yes No Husband Husband No Date_______________ Yes Wife Wife Yes If yes, list approximate date(s):______________ What is your desired parenting schedule? _____________________________________________________________ DR-606 2 Rev. 8/15 American LegalNet, Inc. www.FormsWorkFlow.com PLEASE DESCRIBE THE STRENGTHS AND WEAKNESSES OF YOU AND YOUR (EX)SPOUSE MOTHER'S STRENGTHS MOTHER'S WEAKNESSES ______________________________________ ___________________________________ FATHER'S STRENGTHS ______________________________________ FATHER'S WEAKNESSES ______________________________________ ______________________________________ Describe your current level of communication with your (ex)spouse: ___________________________________________ _________________________________________________________________________________________________ What methods of communication do you use? (ie: phone, text, email, etc.) ______________________________________ What are your babysitting/day care arrangements?________________________________________________________ RELATIONSHIP TO CHILDREN CARETAKER ADDRESS PHONE # _________________________________________________________________________________________________ _________________________________________________________________________________________________ If you feel your child(ren) has/have any physical or emotional problems or school issues which must be considered in the divorce, please describe:______________________________________________________________________________ __________________________________________________________________________________________________ Have any other parties or your spouse made allegations of physical or sexual abuse against you in regard to the child(ren)? If so, please explain:___________________________________________________________________________________ __________________________________________________________________________________________________ Do you have any reason to believe your spouse has been physically or sexually abusive toward the child(ren)? If so, please explain:____________________________________________________________________________________________ ____________________________________________________________________________________________________ Have the children ev