1 Form 6.01A Rev. 1/2018 IN THE COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION MEDINA COUNTY, OHIO GUARDIAND AD LITEM QUESTIONNAIRE THIS DOCUMENT SHALL BE COMPLETED AND RETURNED TO THE GUARDIAN AD LITEM. THIS DOCUMENT SHALL NOT BE FILED WITH THE COURT. A. INFORMATION PERTAINING TO YOU: Your Name: Address: City, State, Zip: Telephone: Email: Social Media: Date of Birth: Social Security #: Your Employer: Address: City, State, Zip: Telephone: Your Attorney: Address: City, State, Zip: Telephone: Email: American LegalNet, Inc. www.FormsWorkFlow.com 2 Form 6.01A Rev. 1/2018 B. INFORMATION PERTAINING TO THE CHILD(REN): Social Media: Date of Birth: Social Security #: School: Address: City, State, Zip: Telephone: Teacher: Grade : Residential Parent for School Purposes: Extra - curricular Activities: Social Media: Date of Birth: Social Security #: School: Address: City, State, Zip: Telephone: Teacher: Grade : Residential Parent for School Purposes: Extra - curricular Activities: American LegalNet, Inc. www.FormsWorkFlow.com 3 Form 6.01A Rev. 1/2018 B. [CONTINUED]: Social Media: Date of Birth: Social Security #: School: Address: City, State, Zip: Telephone: Teacher: Grade : Residential Parent for School Purposes: Extra - curricular Activities: Social Media: Date of Birth: Social Security #: School: Address: City, State, Zip: Telephone: Teacher: Grade : Residential Parent for School Purposes: Extra - curricular Activities: American LegalNet, Inc. www.FormsWorkFlow.com 4 Form 6.01A Rev. 1/2018 C. YOUR CURRENT MARRIAGE: Address: City, State, Zip: Telephone: Email: Social Media: Date of Birth: Social Security #: Date of Marriage: Employer: Address: City, State, Zip: Telephone: Position: Other Child(ren ) [Names and Ages of children who are not subject to this litigation]: 1. 2. 3. 4. D. YOUR PRIOR MARRIAGE(S): 1. Former Spouse: Length of Marriage: Telephone: Email: Social Media: American LegalNet, Inc. www.FormsWorkFlow.com 5 Form 6.01A Rev. 1/2018 Child(ren) from prior marriage [Names and Ages]: 1. 2. 3. 2. Former Spouse: Length of Marriage: Telephone: Email: Social Media: Child(ren) from prior marriage [Names and Ages]: 1. 2. 3. E. PLEASE STATE THE NAME(S), AGE(S) AND RELATIONSHIP(S) OF ANY AND ALL OTHER PEOPLE CURRENTLY RESIDING IN YOUR HOUSEHOLD: N AME A GE R ELATIONSHIP 1. 2. 3. 4. 5. 6. American LegalNet, Inc. www.FormsWorkFlow.com 6 Form 6.01A Rev. 1/2018 F. PLEASE STATE THE NAME(S), ADDRESS(ES), AND TELEPHONE NUMBER(S) OF NO MORE THAN THREE (3) PEOPLE WHOM YOU WOULD LIKE THE GUARDIAN AD LITEM TO INTERVIEW: N AME T ELEPHONE A DDRESS 1. 2. 3. G. PLEASE DESCRIBE THE ISSUE(S) AND/OR CONCERNS THAT YOU HAVE AND THAT YOU WOULD LIKE THE GUARDIAN AD LITEM TO INVESTIGATE: (For example: domestic violence, abuse, neglect, mental health, drug/alcohol abuse) H. PLEASE STATE WHETHER THE CHILD(REN) INVOLVED IN THIS LITIGATION IS/ARE CURRENTLY RECEIVING COUNSELING, AND, IF SO, THE NAME(S), TELEPHONE NUMBER(S) AND ADDRESS(ES) OF THE COUNSELOR(S): C HILD C OUNSELOR T ELEPHONE A DDRESS American LegalNet, Inc. www.FormsWorkFlow.com 7 Form 6.01A Rev. 1/2018 I. PLEASE STATE WHETHER THE CHILD(REN) INVOLVED IN THIS LITIGATION IS/ARE CURRENTLY RECEIVING MEDICAL TREATMENT FOR ANY CONDITION, AND, IF SO, THE NAME(S), TELEPHONE NUMBER(S) AND ADDRESS(ES) OF THE DOCTOR(S): C HILD D OCTOR T ELEPHONE A DDRESS J. PLEASE STATE WHETHER THE CHILD(REN) INVOLVED IN THIS LITIGATION IS/ARE CURRENTLY ATTENTING DAYCARE AND/OR AFTER-SCHOOL CARE, AND, IF SO, THE NAME(S), TELEPHONE NUMBER(S) AND ADDRESS(ES) OF THE CAREGIVER(S) (e.g., BUSINESS, PERSON, OR INSTITUTION PROVIDING THE CARE): C HILD C AREGIVER T ELEPHONE A DDRESS American LegalNet, Inc. www.FormsWorkFlow.com