RETURN TO:

Robert M. Gordon, Ph.D., ABPP

1259 South Cedar Crest Boulevard, Suite #325

Allentown, Pennsylvania 18103-6261

Phone: 610.821.8015 Fax: 610.821.1072,

Please fill out this questionnaire. Be honest. Your responses may be investigated against other sources of information. You may use a word processor as long as you keep the order and exact questions unchanged.

POST MARITAL PARENTING PLAN QUESTIONNAIRE

TODAY’S DATE IS: ___/___/___

YOUR NAME: _____________ _____________________________________ AGE: ______

ADDRESS: ___________________________________________________________________

PHONE: (H) __________________________ (W)_____________________________________

BIRTH DATE___/___/___

OTHER PARENT’S NAME: ________________________________________ AGE: ______

ADDRESS: ___________________________________________________________________
PHONE: (H) __________________________(W) _____________________________________

BIRTH DATE:___/___/___

1. Name of Sex: Current Date of Biological Biological

Child: Age: Birth: Mother: Father:

_________________ M-F ___Yr __Mo ___/___/___ ____________ ___________

2. What is the biological relationship and the legal relationship of yourself and of the other

parent to the children in question?

You: Other Parent:

Biological

Relationship:

Legal

Relationship:

3. As an introduction, please briefly summarize the major aspects of the current situation.

4. How do you think the other parent would describe the current situation? What do you

think the other parent would want to discuss with the evaluator?

5. CURRENT CUSTODY AND VISITATION ARRANGEMENT

The custody and visitation arrangement now in effect began about ___/___/___

This current arrangement is ___ Temporary or ___ Permanent Custody

The current custody and visitation arrangement is (mark a or b)

a. ___ Joint Legal Custody with:

___Residential Custody shared by both you and the other parent

- or -

___Primary Residential Custody with ___you or ___ the other parent

b. ____Sole Legal Custody and Primary Residential Custody with:

___you or ___ the other parent

Describe the current visitation schedule indicating when the children are scheduled to reside with you, the other parent, and/or another custodian.

Days and hours with you:

Days and hours with the other parent or another custodian:

6. Who decided what the current custody and visitation arrangements would be? How

was the decision reached?

7. Are there significant problems or areas of disagreement with the other parent regarding

the current visitation schedule itself? Yes ____ No ____. If “Yes”, please explain.

8. PRIOR CUSTODY AND VISITATION ARRANGEMENTS

Has there been a previous custody or visitation arrangement in effect prior to the current one?

____Yes ____No If “No”, skip to the next section of the questionnaire. This section of the questionnaire refers only to the custody or visitation arrangement that was in effect immediately before the current arrangements.

This prior arrangement was in effect from ___/___/___ to ___/___/___.

This prior arrangement was ___Temporary Custody or ___Permanent Custody.

This prior arrangement was: (mark a or b)

a. ___Joint Legal Custody with

___Residential Custody shared by both you and the other parent.

- or -

___Primary Residential Custody with ___you or ___ the other parent

b. ___Sole Legal Custody and Primary Residential Custody with:

___you or ___ the other parent

9. Describe the prior visitation schedule indicating when the children were scheduled to

reside with you, the other parent, and/or another custodian.

Days and hours with you:

Days and hours with the other parent or another custodian:

10. What led to the change from this previous custody and/or visitation arrangement to the

current one.

11. LEGAL HISTORY

Please provide the name, address, and phone number of each attorney.

Your Attorney: Other Parent’s Attorney:

Name:

Address:

City:

State, Zip:

Phone Number:

12. Describe the extent of the court’s involvement in this matter to date including your understanding of the current orders of the court with regard to any issues you have not already described.

13. Are there any documents that you would like the evaluator to review (such as pleadings, court orders, decrees, affidavits, police reports, letters, school or medical records)? ___Yes ___No If “Yes”, please provide the documents and summarize the major facts that you want the evaluator to gain from reviewing these documents.

14. Have you received any other professional evaluations, recommendations, or opinions related to this matter?

Yes ___ No ___

15. Are any additional professional opinions anticipated? Yes ___ No ___

16. Will you provide copies of any past and future letters or reports to this office? Yes ___ No___. Please explain if appropriate.

17. Are any other professionals involved in this matter such as a Guardian ad Litem (GAL), Court Appointed Special Advocate (CASA), attorney for the child, Family Court Caseworker, Child Protective Services (CPS) Caseworker, teacher, pastor, physician, counselor, therapist, mental health specialist, etc.? Yes ____ No____ If “Yes”, please provide their names and telephone numbers and describe their involvement or role. Indicate if you will have them call the evaluator.

Name Phone Number Involvement or Role:

18. Are there any upcoming court dates or other deadlines of which you are aware? Yes____ No ____. When?

19. Is there any additional information that you would like to present regarding the legal history of this matter?

Yes ___ No ___ If “Yes”, please explain.

20. INDIVIDUAL HISTORY

Provide the name, relationship, age and health status of each of your parents, brothers and sisters. Please list the oldest first. Include any who are deceased and note the year they passed away and the cause of death.

Name: Relationship Age Health Status

21. Describe the relationship between your parents when you were a child. Indicate if they were ever separated or divorced, and if so, when and how often.

22. Do your family, friends or neighbors or those of the other parent have an involvement that you think is significant in the parenting issues? Yes____ No_____. If “Yes”, please explain.

23. Indicate the last two schools you attended, the dates of attendance, the degree(s) earned, and your average grades at those schools.

School Dates Attended Degree Earned Average Grades

24. Did you leave any educational program prior to completion? Yes___ No___. If “Yes”, please explain and describe the circumstances under which you left.

25. Do you have any concerns about the other parent’s educational history that are relevant to the current evaluation? Yes____ No____. If “Yes”, please explain.

26. Describe you work history for your past four employments. Start with your most recent position. Include homemaker or periods of unemployment, where appropriate.

Employer Position Dates Major Reason(s)

Responsibilities for Leaving

27. Do you have concerns about the other parent’s work and professional history that would be relevant to the current evaluation? Yes____ No____. If “Yes”, please explain.

28. How is your general health? Might concerns about your health be raised as part of the evaluation including such concerns as illnesses, injuries, physical fitness, smoking, over-or under eating, etc.? Yes___ No___. If “Yes”, please explain.

29. Do you have concerns about the general health of the other parent that would be relevant to this evaluation? Yes__ No__. If “Yes”, please explain.

30. Have you ever had any psychological counseling or therapy? Yes__ No__

If “Yes”, please give the name of each therapist, the approximate dates that counseling started and ended, and your reasons for entering counseling.

31. Do you consent for the evaluator to consult with your present and past therapists? Yes__No__

Counselor Start-End Dates Reasons for

Name, Address Entering

Phone Number Counseling

32. Have you attended any parenting classes, anger management classes, marriage encounter seminars, or other psychologically oriented classes? Yes__ No__

If “Yes”, please give the name of each class, the approximate starting and ending date, and your reasons for taking each class. Do you consent for the evaluator to consult with your present and past instructor(s)?

Yes___ No___

Name of Class Start-End Dates Reasons for Taking

or Seminar the Class or Seminar

33. Might concerns about intimidating, aggressive, or hostile behavior on your part be raised by the other parent as part of this evaluation? Yes___ No___. If “Yes”, please explain.

34. Do you have any concerns about intimidating, aggressive, or hostile behavior on the part of the other parent that would be relevant to this evaluation? Yes___No___. If “Yes”, please explain.