CHILD CUSTODY MEDIATION QUESTIONNAIRE

 

1.		Name:		____________________________________
		Address:		____________________________________
				____________________________________
		Phone No:		____________________________________
		Date of Birth:		____________________________________
		Employment:		____________________________________
		Educational Backgroud:		____________________________________
		Brief Description of Current Residence:		____________________________________

 

2.

Children: A.      Subject of this action:

Name

Date of Birth

Age

Grade Level

School

_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

 

B.      Other children in household:

Name

Age

relationship to Party

_______________________________________________________ _______________________________________________________ _______________________________________________________

 

3.		Marital/Cohabitation History
		Date of Marriage or Cohabitation (if applicable)		____________________________________
		Date of Separation:		____________________________________
		Cause of Separation (brief explanation):		____________________________________
		Date of Divorce: (if applicable)		____________________________________
		Is a Divorce action pending?		____________________________________
		Current Marital Status/Living Arrangements:		____________________________________
		Brief Description of Current Residence:		____________________________________

(i.e.: Remarriage or Cohabitation - provide name of new spouse or cohabitant)

 

4.

Procedural History: A.      Verbal Custody/Visitation Arrangements: (Describe arrangement with applicable dates)

_______________________________________________________ _______________________________________________________ _______________________________________________________

B.      Written Custody/Visitation Arrangements: (Summarize arrangement and applicable dates)

_______________________________________________________ _______________________________________________________ _______________________________________________________

C.      Orders of Court: (Summarize or Attach, including Orders from foreign jurisdictions and dates of entry)

_______________________________________________________ _______________________________________________________

5.

Current Custody/Visitation Arrangement:

_______________________________________________________ _______________________________________________________ _______________________________________________________

6.

Proposed changes in current custody/visitation arrangement:

_______________________________________________________ _______________________________________________________ _______________________________________________________

7.

Concerns, if any, about the other party regarding custody/visitation of the child(ren):

_______________________________________________________ _______________________________________________________ _______________________________________________________

8.

Does child(ren) have any special needs?

_______________________________________________________ _______________________________________________________ _______________________________________________________

9.

Have home studies or psychological evaluations been completed? If so, by whom and dates:

_______________________________________________________ _______________________________________________________ _______________________________________________________

 

________________        Date

_____________________________            Signature of Party