FRD-10 (3/16) PARENT QUESTIONNAIRE & INFORMATION SHEET New Address FOR COURT USE ONLY CASE NO._________________________________ JUDGE:___________________________________ P:_____________________ D:_________________ DATE RECEIVED:__________________________ A. PERSONAL: name street address city home phone state work phone zip code Please list highest grade completed and/or any specific training you may have received: Name and address of current employer: Current work hours and days: Starting date: List all other jobs held during the past 3 years, beginning with the most recent, Including dates of employment: your attorney=s name phone fax business address city state zip code B. MARITAL HISTORY: What have been the major problems in the marriage? __________________________________________ __________________________________________________________________________________________. Were there any previous separations? Who initiated the separation? (insert name) Who left the home? (insert name) Have you filed for divorce before? If so, where?_______________________________________________ no date yes date no yes American LegalNet, Inc. www.FormsWorkFlow.com 2 C. 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 yes yes What are your feelings with regard to your spouse having custody? _______________________________ __________________________________________________________________________________________ D. MEDIATION: ** please review the enclosed mediation brochure ** Parents are encouraged to work together to make the best possible parenting arrangement for their children. Mediation provides a structured, open discussion of many options, a means for the parents to retain control of the outcome of their divorce, and is generally quicker, more satisfying, and less expensive than litigation. Are you interested in having the option to mediate with your spouse? no yes If you have questions about whether or not mediation would be appropriate for your case, please call 225-4539. E. FINANCES and CHILD SUPPORT: Are you on any form of government assistance? no no yes yes If so, what kind? If so, who filed? Was bankruptcy filed during the marriage? Place & date of filing; case number; other relevant information: Is there a court order for child support for children of this marriage? Is child support being paid without a court order? no no yes yes If so, who pays the support: you your spouse What is the amount per child, and per week or per month? Is this amount paid or received on a regular basis? no yes American LegalNet, Inc. www.FormsWorkFlow.com 3 F. HEALTH: Poor Fair Good Excellent Are there any physical problems? Please describe: you your spouse Are you or your spouse currently under the care of a physician, psychiatrist, or psychologist? Their name you: your spouse: phone # no no address yes yes If so, please provide the following information: If you are currently on any kind of prescription drug, please list, and give the name of the doctor who prescribed the medication: Have you or your spouse ever been institutionalized for any reason? Doctor=s name you: your spouse: phone # no no yes yes If so, please provide the following information: Institution name and address Do you drink alcohol? Does your spouse? Have you ever abused drugs? Has your spouse ever abused drugs? no no no no yes yes yes yes If yes, how often? If yes, how often? If yes, please give full explanation: If yes, please give full explanation: G. HOME IN WHICH YOU CURRENTLY RESIDE: Type of dwelling: Number of bedrooms: Names of other persons living in the home: Relationship: American LegalNet, Inc. www.FormsWorkFlow.com 4 H. CHILDREN of CURRENT MARRIAGE: name of child sex date of birth residing with: if emancipated OTHER CHILDREN WHO RESIDE WITH YOU: name of child sex date of birth residing with Do you have custody? Are you requesting child support? How much?_____________________________ no no yes yes Describe the children=s adjustment to the separation/divorce: _____________________________________ __________________________________________________________________________________________. What are the babysitting/day care arrangements? ______________________________________________ __________________________________________________________________________________________. 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: ____________________________________________________________ ________________________________________________________________ __________________________. American LegalNet, Inc. www.FormsWorkFlow.com 5 Have the children ever been abused or neglected? Were the police, Children Services, or Juvenile Court ever contacted? If so, what agency, and in which county? __________________________ Please list the names of the workers that you have been involved with at Children Services or Juvenile Court and describe the incident: _____________________________________________________ __________________________________________________________________________________________. Please describe any conflict areas in your parenting styles; such as: differences in child rearing philosophy, discipline, religion, communication, hygiene, etc.: _____________________________________ __________________________________________________________________________________________. no no yes yes I. VISITATION Is there a court order for visitation at this time? Do you have visitation periods with the children on a regular basis? What amount of time do you spend with the children? What amount of time does your spouse spend with the children? Have you ever denied your spouse contact with the children? If so, please explain: no no yes yes no yes Have you been denied contac