Name * First Name Last Name Referred by: * Date of birth: * MM DD YYYY Current marital status: * Length of relationship or marriage: * Date of separation: * Address: * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Emergency Contact: (###) ### #### PLEASE TELL ME ABOUT YOUR CHILDREN: AGES, GENDER/PRONOUNS, MEDICAL CONDITIONS, PERTINENT MEDICAL OR MENTAL INFO, HEALTH TREATMENT, RELATIONSHIP WITH DAD, AND ANY OTHER CONCERNS: * WHAT IS YOUR CURRENT CUSTODY ARRANGEMENT (TIME DIVISION, LEGAL AND PHYSICAL CUSTODY, ETC.: * PROVIDE A SUMMARIZED DESCRIPTION OF YOUR DIVORCE OR CHILD CUSTODY BATTLE: * PLEASE DESCRIBE YOUR EX-PARTNER - PROFESSION, BACKGROUND, ADDICTIONS, STRENGTHS, WEAKNESSES, ANYTHING ELSE I SHOULD KNOW. WHAT IS YOUR PERCEPTION OF HOW OTHER VIEW HIM? * WHAT TOPICS ARE YOU MOST INTERESTED IN EXPLORING: EXAMPLES MAY INCLUDE SETTING BOUNDARIES, COMMUNICATION, STRATEGY, UNDERSTANDING THE SYSTEM, EMOTIONAL SUPPORT, DOCUMENTATION, PREPARATION FOR EVALUATIONS, ETC. PLEASE LIST 3 ITEMS YOU WANT TO FOCUS ON IN OUR TIME TOGETHER. * ATTORNEY: ARE YOU CURRENTLY WORKING WITH AN ATTORNEY, AND, IF SO, WHO IS YOUR ATTORNEY? DO YOU FEEL THAT YOUR ATTORNEY UNDERSTANDS HIGGH-CONFLICT INDIVIDUALS? PLEASE EXPLAIN: * DIVORCE PROFESSIONALS (PAST AND PRESENT): ARE YOU CURRENTLY WORKING WITH CUSTODY EVALUATORS, MINOR'S COUNSEL (GAL), CHILD WELFARE SERVICES OR OTHER LEGAL PROFESSIONALS? ANY DETAILS ARE HELPFUL AND APPRECIATED. PLEASE PROVIDE THE NAME OF THE JUDGE AND ANY PROFESSIONALS INVOLVED IN YOUR CASE. * THERAPY: ARE YOU (ORYOUR CHILDREN) CURRENTLY UNDER THE CARE OF A THERAPIST? IF SO, PLEASE DESCRIBE YOUR RELATIONSHIP WITH THEM. D O YOU FEEL THEY UNDERSTAND TRAUMA AND HIGH CONFLICT DIVORCE? * WHAT IS YOUR KNOWLEDGE OF THE COURT SYSTEM? (SCALE OF 1-10) * IF YOU WERE TO MEET WITH A COMPLETE STRANGER FOR ONE HOUR, HOW WOULD THEY DESCRIBE YOU? * WHAT ARE YOUR GREATEST STRENGTHS AND BIGGEST WEAKNESSES? * WHAT RESOURCES HAVE BEEN MOST HELPFUL TO YOU IN THIS JOURNEY (BOOKS, PODCASTS, YOUTUBE ETC)? * ANYTHING ELSE? Thank you! Thank you for taking the time to complete this form. Please know that all of your information is confidential. I look forward to working with you. Be kind to yourself.