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,
Email to: gordon@cedarcrest7.com
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.
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 ___/___/___ ____________ ___________
_________________ M-F
___Yr __Mo ___/___/___ ____________ ___________
_________________ M-F
___Yr __Mo ___/___/___ ____________ ___________
_________________ M-F
___Yr __Mo ___/___/___ ____________ ___________
_________________ 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:
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.
36. Might concerns about your use of alcohol
be raised as part of this evaluation? Yes___No___. If
“Yes”, describe any history of problems involving your use of alcohol and
describe any changes in this pattern in the past and explain.
37. Do you have any concerns about the use of
alcohol by the other parent that would be relevant to this evaluation? Yes___No___. If “Yes”, please explain and indicate
whatever you know about the use of alcohol by the other parent.
38. Might concerns about your use of non-legal
drugs be raised as part of this evaluation?
Yes___No___.
If “Yes”, describe the history of your use of drugs and describe any
changes in this pattern in the past and explain.
39. Do you have concerns about the use of
non-legal drugs by the other parent that would be relevant to this
evaluation? Yes___No___. If “Yes”, please explain and describe what
you know about the other parent’s use of drugs.
40. Has there been any contact with any
professional or agency that was related to mental illness, violence, drug use,
counseling, arrests, or incarcerations by you
Yes___No___, your family Yes___No___,
the other parent Yes___No___, or the other parent’s
family Yes___No___ that you have not already
described? If “Yes” to any, please
explain.
41. MARITAL HISTORY
Have you had
any marriages or other long term intimate relationships prior to the one
with the other parent? Yes___No___. If
“Yes”, please provide the beginning and ending dates of each relationship, the
type of relationship it was (e.g. married, lived together, etc.), a brief description
of the current quality of that adult relationship, and the names and ages of
any children from those relationships, including step-children.
Start/End Type of
Adult Current Quality
of Adult Child’s Name Age
Dates Relationships Relationship
42. If you have children from a previous
relationship, describe each custody and visitation arrangement, the amount of
time you actually spend with each child, and the quality of your current
relationship with each child. Be
specific.
Child’s Name Current
Custody Amount of Time
You Quality of Your
and
Visitation Actually
Spend with Current
Arrangement the Children Relationship
43. This question requests a brief history of
your relationship with the other parent.
Starting with the earliest first, present in chronological order a
listing of the approximate dates of events such as when you met, lived
together, married, had miscarriages or abortions, had children, had serious
marital problems, moved, had affairs, discussed divorce, had counseling,
separated, reconciled, filed for dissolution, got divorced, experienced custody
or visitation problems, filed for modification etc.
Date Event
or Occurrence
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44. Did you contribute significantly to the problems in
your relationship with the other parent? Yes___No___. If “Yes”, describe how you contributed to the
problems. Indicate when each problem
started and when each problem became serious.
45. Did the other parent contribute significantly to
the problems in your relationship? Yes___No___. If “Yes”, describe how the other parent contributed
to the problems. Indicate when each
problem started and when each problem became serious.
46. What led to the ultimate break-up of the
relationship with the other parent? Who
initiated the decision and action to end the relationship? What impact has this had on the current
situation?
47. Between the start and the end of your
relationship with the other parent, were you involved in any other intimate
relationships? Yes___No___. If “Yes”, please describe the relationship
between your children and the other person(s).
48. Are you currently involved in any intimate
relationships? Yes___No___. If “Yes”, please describe the relationship
between your children and person with whom you currently have an intimate
relationship. What do you contemplate to
be your future involvement in this relationship? Describe any potential changes in your living
arrangements.
49. Between the start and the end of your
relationship, do you think that the other parent was involved or is currently
involved in any intimate relationships with other persons? Yes___No___. If “Yes”, please describe any relationship
between your children and each other person.
50. PARENTING HISTORY
Did you and
the other parent separate more than one year ago? Yes___No___. If “Yes”, you may skip this question. In the last six months that you and
the other parent lived in the same residence, indicate about how many times you
and the other parent typically....
You: Other
Parent:
dressed the children... ___
times per week ___times
per week
cooked for or fed them... ___times
per week ___times per
week
bathed them... ___times
per week ___times per
week
toileted them... ___times
per week ___times per
week
read to them... ___times
per week ___times per
week
played with them... ___times
per week ___times per
week
helped them with homework... ___times
per week ___times per week
disciplined them... ___times
per week ___times per
week
put them to bed... ___times
per week ___times per
week
woke them in the morning... ___times
per week ___times per
week
took them to/from school... ___times
per week ___times per
week
got up in the night with them... ___times per week ___times
per week
shopped for their clothes... ___times
per week ___times per
week
shopped for their toys and books... ___times per week ___times
per week
stayed home with them when
they were sick... ___times per week ___times per week
took them to/from religious
activities... ___times per week ___times per week
took them to/from sports and
school
activities... ___times
per week ___times per
week
other not mentioned above...
specify:
___times
per week ___times per
week
51. What percent of the parenting of the
children do you estimate you provided in the last six months prior to
separation?
__0%-25% __25%-34%
__35%-44% __45%-54% __55%-64%
__65%-74% __75%- 100%
52. Describe the involvement of you and the
other parent with school personnel and school activities. Is there any significant disagreement or
conflict between you and the other parent in the area of education for the
children? Yes___No___.
If “Yes”, please explain.
53. Describe the involvement of you and the
other parent in the health care for each of the children. Is there any significant disagreement or
conflict between you and the other parent in this area? Yes___No___. If “Yes”, please explain.
54. Describe the involvement of you and the
other parent in each of the children’s religious experiences and training. Is there any significant disagreement or
conflict between you and the other parent in these areas? Yes___No___. If “Yes”, please explain.
55. Describe the involvement of you and the
other parent in any other special interest, activity, talent, trait, ability,
or skill that each of the children enjoys.
Is there any significant disagreement or conflict between you and the
other parent in these areas? Yes___No___. If
“Yes”, please explain.
56. Might concerns be raised about the
possibility that any child might be or might have been “at risk” for physical,
sexual, or emotional abuse neglect, or exploitation while the child is was in
your care? Yes___No___. If “Yes”, please explain.
57. Do you have concerns about the possibility
that any child might be or might have been “at risk” for physical, sexual, or
emotional abuse, neglect, or exploitation while the child is/was in the care of
the other parent? Yes___No___. If “Yes”, please explain.
58. Do you have concerns that any child might
be or have been “at risk” for abuse, neglect, or exploitation, from anyone else
that you or the other parent knows? Yes___No___. If
“Yes”, please explain.
59. To the best of your knowledge, has anyone
in your family (including you), anyone in the other parent’s family (including
the other parent), or any of the children been the victim of any form of abuse,
neglect, or exploitation that you have not already mentioned. Yes___No___. If “Yes”, please explain.
60. Do you believe that any of the children
could benefit from any special services related to speech, hearing, or sight
problems, or from other physical or psychological problems, developmental
delay, or chemical addictions? Yes___No___. If
“Yes”, please explain.
61. Is
there any additional significant issues that might be raised regarding the
parenting of any of the children? Yes___No___. If
“Yes”, please explain.
62. Is there additional information that you
would like to provide about your marital or relationship history or about than
of the other parent? Yes___No___. If “Yes”, please explain.
63. How well have you and the other parent
resolved differences of opinion regarding the welfare of the children in the
past three months? Has this been
typically by telephone, in meetings, through attorneys, or by other means? Please describe any changes in these patterns
and explain.
64. Please indicate what you think are the most
likely major areas for future disagreement or conflict between you and the
other parent.
65. Do you believe that there is currently a
“primary parent” to whom the children feel more attached or with whom the
children feel more involved? Yes___No___. If
“Yes”, indicate who that parent is and describe the way in which you believe
that person is the “primary parent” for each child.
66. If you believe that one of the parents is
not the “primary parent”, why do you think that parent has not been more
involved with the children?
67. What plans and preparations have you made
regarding the children’s future?
a.
schooling/childcare...
b.
health care...
c.
living arrangements...
d. moral instruction...
e.
financial security...
f.
contacts with other children...
g.
contacts with relatives...
h.
other, specify...
68. Describe your current residence and
neighborhood indicating where the children do homework, sleep, have friends,
and play.
69. Describe the other parent’s residence and
neighborhood indicating where the children do homework, sleep, have friends,
and play. If you do nor know, please
explain.
70. Might concerns about the residences,
living conditions, or neighborhoods of either parent be raised as an issue in
this evaluation? Yes___No___. If “Yes”, please explain.
71. Have you told the children about the
current legal situation (separation, dissolution, modification, contempt,
etc.). Yes___No___.
Have you shown them any of the court papers or any reports, opinions, or
recommendations? Yes___No___. If “Yes”, to either question, please explain.
72. Do you think the other parent has told the
children about the current legal situation?
Yes___No___.
Do you think the other parent has shown them any of the court papers or
reports, opinions, or recommendations? Yes___No___. If
“Yes”, to either question, please explain.
73. Have any of the children said anything to
you or to others with regard to their feelings, opinions, and preferences about
custody and visitation? Yes___No___. If
“Yes”, please explain.
74. Why do you think the children have said
the above? Also, indicate whether you
think the children spoke spontaneously or were questioned.
75. How much weight do you think should be
given to the children’s feelings, opinions, and preferences? Why?
76. Do you believe that having a substantial
future relationship with he other parent is important to the children’s
welfare? Yes___No___. Please explain you answer. Describe what you believe would be the value
or the cost to the children of a future relationship with the other parent.
77. What do you believe would be the best
custodial and visitation arrangement for the children? Please mark #1 or #2.
1.
(__) Joint Legal Custody with
(_) Residential Custody shared by both you and
the other parent
- or -
2.
(__) Sole Legal Custody and Primary Residential Custody with:
(_) you or (_) the other
parent
78. Describe the living arrangement/caretaking
schedule that you believe would be best for the children. Indicate the schedule of the days and the
hours that each of the children would be in your care and in the care of the
other parent.
Days and hours with you:
Days and hours with the other
parent:
79. Describe the schedule you think best for
the following three school vacations:
1) Winter Vacation (Including Christmas
Eve/Day and New Year’s Eve/Day):
2) Spring Vacation (Including Easter
Sunday):
3) Summer Vacation (Including July Fourth
and Labor Day):
80. Describe the yearly schedule you think
would be best for each of the following occasions:
With With other Alternate No Special
you:
parent: yearly: schedule: Other:
Presidents
Day... (__)
(__) (__) (__)
M.L. King’s
Day... (__) (__) (__) (__)
Valentine’s
Day... (__) (__)
(__) (__)
Memorial
Day... (__)
(__) (__) (__)
Halloween... (__) (__)
(__) (__)
Children’s
Birthday... (__) (__)
(__) (__)
Your
Birthday... (__)
(__) (__) (__)
Other Parent’s
Birthday... (__)
(__) (__) (__)
Mother’s
Day... (__)
(__) (__) (__)
Father’s
Day... (__)
(__) (__) (__)
Religious
Holidays... (__) (__)
(__) (__)
81. What is the maximum number of days that
you think the children could routinely be separated without ill effect from you
and their other parent for schedules visitation/caretaking and occasionally for
longer vacations?
ROUTINE
SEPARATION: OCCASIONAL
SEPARATION:
From yourself: up to _____days up
to ____days
From other
parent: up to _____days up to ____days
82. Have any of the children resided in the
past with someone other than the biological parents? Yes___No___. If “Yes”, please explain.
83. What has been the child’s experience with
separation from each of the parents in the past? What is the longest that each child has been
separated from each of the parents? How
did each child react to being separated?
Please explain each answer.
84. What are your opinions regarding telephone
contact during separations? Consider who
should initiate calls and should there be any limitations on calling? Yes___No___. Please explain.
85. Do you contemplate any move(s) of your
residence in the foreseeable future? Yes___No___. If
“Yes”, please explain.
86. Are you willing to arrange your current
and future residence and living circumstances such that the access of any of
the children to the other parent is not decreased? (This would include where you live, ease of
access to transportation, use of a telephone, etc.) Yes__No___. If “No”, please explain.
87. Do you believe that the other parent might contemplate limiting the access of any of the children to you? Yes___No___. If “Yes”, please explain.
88. What is you work schedule? How often are you out of town? How might these factors effect the children’s
schedules?
89. What is the work schedule of the other
parent? How often is the other parent
out of town? How might these factors
effect the children’s schedules?
90. What are the children’s school
schedules? When are other activities in
which the children engage. How might
these factors effect the children’s visitation schedules?
91. Please provide any additional information that you would like to have considered in this evaluation. Feel free to include information about concerns, incidents, decisions, judgments, or patterns of behavior that you have not already mentioned.
92. CONCLUSION
Please
summarize what you believe to be the most important concerns that you have
presented in this questionnaire.
Signed____________________________________________ Date____/___/___
How many hours
did you spend completing this questionnaire?
____ Hours
Did you
adequate time to complete it? Yes___No___
How adequate
was the questionnaire in providing to you an initial opportunity to present a
description of your concerns?
VERY VERY
ADEQUATE
ADEQUATE NEUTRAL INADEQUATE INADEQUATE
+4 +3 +2 +1 0 -1 -2 -3 -4
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