Getting to Know You and Your Family - Google Forms › wzukusers › user... · Getting to Know You...
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Getting to Know You and Your Family Click on Video
Basic information about you and your family
1. Person filling out form:
2. Date of birth
3. Address
4. Cell Phone:
5. Home Phone:
6. Employer:
7. Employer Address:
8. Occupation:
9. Level of Education:Mark only one oval.
High School
Bachelors
Masters or Doctorate
10. ExSpouse Name:
11. Address:
12. Cell Phone:
13. Date filed for Divorce:
Example: December 15, 2012
14. Court Case Number:
15. Name of Respondent:
16. Name of Petitioner:
17. Court ordered:Check all that apply.
Special Master / Parent Planning Coordinator
Reunification Therapy
Child Therapy
Binuclear Family Therapy
Parent Education
Other:
18. Date of above Court order:
Example: December 15, 2012
19. Attorney for Respondent:
20. Attorney's Address, Phone and Email:
21. Attorney for Petitioner:
22. Attorney's Address, Phone and Email:
23. Child's Attorney:
24. Child's Attorney's Address, Phone and Email:
25. Presiding Judge and Courtroom #:
26. Court Address and County:
27. Children's Names, Date of Birth and Ages :(associated with exspouse)
28. Current Custody ArrangementCheck all that apply.
Mother Sole Legal and Physical
Father Sole Legal and Physical
Joint Physical and Legal
Joint Legal, Mother Physical Custody, Father Visitation
Joint Legal, Father Physical Custody, Mother Visitation
Father's Visitation Supervised
Mother's Visitation Supervised
Supervision by Family/Friend
Supervision by Program
Supervision by Law Enforcement
29. Describe Visitation Schedule
Most important things you want from our work together.
30. What are 3 hopes/goals that you want to get from our work together?
Let's get to know your children.
31. Please check the boxes that most fit your children (prior to divorce). Child #1:Check all that apply.
Happy
Irritable
Depressed
Loving
Shy
Oppositional
Anxious
Selfish
Attention seeker
Mean spirited
Obsessive and or Compulsive
Somatic (body) concerns
32. Please check the boxes that most fit your children (prior to divorce). Child #2:Check all that apply.
Happy
Irritable
Depressed
Loving
Shy
Oppositional
Anxious
Selfish
Attention seeker
Mean spirited
Obsessive and or Compulsive
Somatic (body) concerns
33. Please check the boxes that most fit your children (prior to divorce). Child #3:Check all that apply.
Happy
Irritable
Depressed
Loving
Shy
Oppositional
Anxious
Selfish
Attention seeker
Mean spirited
Obsessive and or Compulsive
Somatic (body) concerns
34. Please check the boxes that most fit your children (prior to divorce). Child #4:Check all that apply.
Happy
Irritable
Depressed
Loving
Shy
Oppositional
Anxious
Selfish
Attention seeker
Mean spirited
Obsessive and or Compulsive
Somatic (body) concerns
35. Are there any problems at school for child #1?Check all that apply.
Perfectionistic
Good Grades
Inconsistent Grades
Poor Grades
Attention Deficit
Learning Disabilities
Significant Homework Struggles
Procrastinates and/or Appears Lazy
School Performance Anxiety
Frequently Doesn't Want to Go to School
36. Are there any problems at school for child #2 ?Check all that apply.
Perfectionistic
Good Grades
Inconsistent Grades
Poor Grades
Attention Deficit
Learning Disabilities
Significant Homework Struggles
Procrastinates and/or Appears Lazy
School Performance Anxiety
Frequently Doesn't Want to Go to School
37. Are there any problems at school for child #3 ?Check all that apply.
Perfectionistic
Good Grades
Inconsistent Grades
Poor Grades
Attention Deficit
Learning Disabilities
Significant Homework Struggles
Procrastinates and/or Appears Lazy
School Performance Anxiety
Frequently Doesn't Want to Go to School
38. Are there any problems at school for child #4 ?
Check all that apply.
Perfectionistic
Good Grades
Inconsistent Grades
Poor Grades
Attention Deficit
Learning Disabilities
Significant Homework Struggles
Procrastinates and/or Appears Lazy
School Performance Anxiety
Frequently Doesn't Want to Go to School
39. Have any of the following occurred at school?
Check all that apply.
Teacher Parent Meeting Due to Concerns
504 Plan
Student Study Team Meeting
Psychoeducational Testing (by school)
Psychoeducational Testing (privately)
IEP Plan
Would like a plan in place
40. For Which Child?
The good times with your kids
41. Describe something you really enjoy doing with child #1
42. Describe something you really enjoy doing with child #2
43. Describe something you really enjoy doing with child #3
44. Describe something you really enjoy doing with child #4
45. What characteristics of your children are most irritating for you ?Check all that apply.
Not listening
Arguing/ Bossy
Doddling
Clingy Extrareliant on you
Defiant
Poor Communicator
Shy
Damage Property
Attention Seeking
Vengeful
They Give Up
Withdraw
OverUse of Electronics
46. How do you typically respond or discipline your children?Check all that apply.
Remind, Coax, Give Warnings
Time outs / Removal of Priveleges
Scream or Put Downs
Talk it out
Spanking
Give more chores
Focus on good behaviors
Show a lack of faith in them
Overhelp
Take it personally
Frequently give in
When your child struggles or acts out, what do you feel like?
47. Check all that apply.
Annoyed
Worried
Guilty
Authority is challenged
Defeated/ Wanting to give up
Wish to retaliate or get even
Hurt / dissapointed
Disbelieving / disgusted
Despair, hopeless
Helpless, inadequate
Other:
48. How would you like to better respond to your childCheck all that apply.
More patience
Offer them more support and confidence
Be calmer, less angry
Show less annoyance
Hold the rules better, be firm and kind
Show more expression of love
Stop comparing them to others
Lessen my expectations of them
Have more faith in them
Develop more routines and helpful structure
Acknowledge their feelings more
Develop mutual respect
Don't give up on them
Encourage their strengths
Engage them in problem solving
A challenge: Try to put resentments aside for a moment... Ok
now, let's go back and look at the beginning of your
marital/partner relationship.Visualize the 1st time you met your spouse, the time you felt most connected....now fill out the following....
49. Name at least 5 characteristics that attracted you to your partnerCheck all that apply.
Kind, Sweet
Giving
Shy
Smart
Understanding
Successful
Assertive
Confident
Good with kids
Athletic, Energetic, Took care of their body
Good moral person
Friendly, Outgoing
Good looks, chemistry
Engaging, good communicator
Calming, supportive
Sexy, sexual
Other:
Now let's look at the ugly, the ending of your relationship.
50. Describe a typical fight in your marriage: My ex would say/do/not do:
51. I would then feel/say/do/not do:
52. Then we would end up:Check all that apply.
Fight verbally with no resolve
Fight verbally with eventual resolve
I would withdraw
Partner would withdraw
I would turn to drinking/pills/other substances to escape
Partner would turn to drinking/pills/other substances to escape
Talk it out with satisfactory resolve
Partner would become defensive with no satisfying resolve
Other
53. Check the issues that closely resemble the reasons for divorce.Mark only one oval per row.
By Partner
Infidelity
Chronic fighting
Boring, emotionally withdrawn,
gone
Excessive drinking / substances
Financial problems
Emotionally nonunderstanding
Demanding, nagging,
overwhelming
Untreated mental health issue
Physical fighting
Controlling
Threatening (describe below)
Verbal/Emotional abuse
54. Check the issues that closely resemble the reasons for divorce.Mark only one oval per row.
By Self
Infidelity
Chronic fighting
Boring, emotionally withdrawn,
gone
Excessive drinking / substances
Financial problems
Emotionally nonunderstanding
Demanding, nagging,
overwhelming
Untreated mental health issue
Physical fighting
Controlling
Threatening (describe below)
Verbal/Emotional abuse
55. Further Description:
Briefly describe your own parents marriage
56. Did they stay marriedMark only one oval.
Yes relatively happy
Yes unhappily
No Divorced
Other:
57. Check off characteristics that best describe your parents (figures most influential inyour life)Mark only one oval per row.
Mother Figure
Caring
Helpful
Dependent
Smart
Controlling
Verbal Fighting
Abusive or Neglectful
Nagging
Alcohol or Drug Abuse
Anxious
Depressed
58. Check off characteristics that best describe your parents (figures most influential inyour life)Mark only one oval per row.
Father Figure
Caring
Helpful
Dependent
Smart
Controlling
Verbal Fighting
Abusive or Neglectful
Nagging
Alcohol or Drug Abuse
Anxious
Depressed
59. Describe their marriageCheck all that apply.
Solid and mostly happy
Not much intimacy, more roommates
Waves of verbal fighting and coming back together
Lots of criticizm and judgementalness
Domestic Violence
Infidelity
Abuse of Alcohol or Substances
I'd like you to imagine that you are a kind knowledgablechild centered judge, as the judge what would you do/order
for your children?
60. I want this Judge to: (please describe)
61. As this judge, you would order what Custody Arrangement
Check all that apply.
50/50
Ex to have visitation every other weekend
Ex to have more than every other weekend but less than 50/50
Ex to have no visitation
Ex to have supervised or limited visitation
How have the children been doing during this divorce
process?
62. Overall how are they doing? (Child #1)Mark only one oval per row.
Child #1
Don't appear to be any differentSome changes in negativedirectionClearly hurting or sufferingSome relief & positive experienceUsed to it and doing alright
63. Overall how are they doing? (Child #2)Mark only one oval per row.
Child #2
Don't appear to be any differentSome changes in negativedirectionClearly hurting or sufferingSome relief & positive experienceUsed to it and doing alright
64. Overall how are they doing? (Child #3)
Mark only one oval per row.
Child #3
Don't appear to be any different
Some changes in negative
direction
Clearly hurting or suffering
Some relief & positive experience
Used to it and doing alright
65. Overall how are they doing? (Child #4)
Mark only one oval per row.
Child #4
Don't appear to be any different
Some changes in negative
direction
Clearly hurting or suffering
Some relief & positive experience
Used to it and doing alright
66. If they are struggling, what are you most worried about for them?
Mark only one oval per row.
Child #1
School grades
School behavior
Home behavior
Rule compliance
Anxiety
Sadness
Anger
Withdrawal
Irritability
67. If they are struggling, what are you most worried about for them?
Mark only one oval per row.
Child #2
School grades
School behavior
Home behavior
Rule compliance
Anxiety
Sadness
Anger
Withdrawal
Irritability
68. If they are struggling, what are you most worried about for them?Mark only one oval per row.
Child #3
School gradesSchool behaviorHome behaviorRule complianceAnxietySadnessAngerWithdrawalIrritability
69. If they are struggling, what are you most worried about for them?Mark only one oval per row.
Child #4
School gradesSchool behaviorHome behaviorRule complianceAnxietySadnessAngerWithdrawalIrritability
Any unfortunate tragedys during your children's life
(besides divorce)?
70. Check all that apply.
Deaths
Physical Illness
Sexual Abuse
Physcial Abuse
Witness to Domestic Violence
Witness to parental substance abuse
Other:
71. Describe the above further:
How is your child's health?
72. Mark only one oval per row.
Child #1
GoodOne or two issues of concernPoor (Explain)
73. Mark only one oval per row.
Child #2
GoodOne or two issues of concernPoor (Explain)
74. Mark only one oval per row.
Child #3
GoodOne or two issues of concernPoor (Explain)
75. Mark only one oval per row.
Child #4
GoodOne or two issues of concernPoor (Explain)
76. Describe further:
How about you? How have you been during this divorce
process?
77. On average, how is your level of anxiety?Mark only one oval.
1 2 3 4 5
Not there Horrible
78. On average, how depressed are you?Mark only one oval.
1 2 3 4 5
Fine, not
depressed
Depressed with suicidal
thoughts
79. On average, how angry are you?Mark only one oval.
1 2 3 4 5
Not
angry
Furious, consumes my thoughts
frequently
80. Have you increased or turned more to alcohol or other substances since the divorceprocess?Mark only one oval.
1 2 3 4 5
No Yes, a lot
81. Do you have support through a therapist?Check all that apply.
Yes
No
In the past, yes
Seeing a psychiatrist for medication
Other:
82. If any, what medications are you currentlytaking?
83. Who is your therapist? (name, address, phone, email and fax)
84. Who prescribes the above medications (name, address, phone, email, fax)
Prior to divorce, how were you doing?
85. Mark only one oval.
1 2 3 4 5
Well, no major issues Suffering
Any health issues for you?
86. Mark only one oval.
Good
One or two issues
Poor
Other:
Now, let's get to know you as a parent.Involvement
87. How loving and expressive are you with your kids
Mark only one oval.
1 2 3 4 5
Not at all Very
88. How involved are you in your children's school/homework?
Mark only one oval.
1 2 3 4 5
Not at all Very Involved
89. How involved are you in your children's extracurricular activities?
Mark only one oval.
1 2 3 4 5
Not at all Very Involved
90. How involved are you in your children's religious education?
Mark only one oval.
1 2 3 4 5
Not at all Very Involved
91. Choose words that describe your parenting style
Check all that apply.
Flexible
Negotiater
Parents should always have the power
Children should always respect their parents
Fair limit setting
Spanking, grabbing, pinching
Screamer
Commanding respect
Teach through modeling
Other:
92. Please list the top 3 values you have tried to instill in your children:
Based on the current custody arrangements, how is the coparenting working?
93. Overall, how is the coparenting going?Mark only one oval.
1 2 3 4 5
Amicable, it's workingok
Horrific, destructive, nonexistant
94. Generally do you think your coparent loves his/her children?Mark only one oval.
1 2 3 4 5
Not at all Absolutely
95. Check off areas of concerns you may have re: your partner
Check all that apply.
Saying negative comments about me to the kids
Manipulating them into thinking I am the "bad guy"
Frequently interrupts my time with the kids via phone/text etc.
Does not send school/health information to me in a timely fashion
Does not spend quality time with the kids
Poor parenting
Abusive with kids
Does not follow courts orders regarding drop off/pick up times
Does not use the allotted visitation time
Contacts me too frequently
Contact with me is adversarial frequently
Lying to me
Lying to children
Mediocre parenting
Involves a new partner inappropriately
Other:
96. What terms best fit for your coparenting relationshipMark only one oval per row.
Husband
Hostile/Antagonistic
Friendly/Respectful
Civil
Fluctuates Civil to Game Play
Manipulative
Cold/Distant
97. What terms best fit for your coparenting relationshipMark only one oval per row.
Wife
Hostile/Antagonistic
Friendly/Respectful
Civil
Fluctuates Civil to Game Play
Manipulative
Cold/Distant
Lets look at your child's daily and holiday commitments andsupport by coparent.
98. Overall, are the kids getting to their commitments on time and being supported by coparent?Mark only one oval.
1 2 3 4 5
Much of the time, going
well
Many problems, little
support
99. How are holidays, special occasions, vacations handled by coparent?Mark only one oval.
1 2 3 4 5
Goes pretty well Huge fighting and struggles
Powered by
100. Check all issues you wish to address:Check all that apply.
Who pays for what
Health Decisions
School Decisions
Extracurricular Decisions
Transfer/Sharing of Information
Pick up/Drop off Exchange
Parenting Style
Discipline Type
Step/Partner Involvement
Mental Health Issues
Addiction Issues
Abuse
Parent Allienation
BREATHE, Stand back and look at the bottom line... What do
you want most for your children?
101.