Screening for Parent-Child Relationship Repair (PCRR) Services

Please complete and return this form to me at deborah@andersonpsychology.com. Note that a court order or parenting consultant (PC) decision is required in order for me to work with your family.

Part I. General Screening Questionnaire for PCRR Services

Your name

Date

Are you the “in” parent or the “out” parent? (The “out” parent is the parent with whom the child or children are resisting or refusing contact)

1. Names and ages of joint children:

Add new row

2. How long has each child been apart from the “out” parent? Indicate the number of continuous months apart with no contact

months

3. Do you object to the child/children having a relationship with the other parent?

Yes No

4. Do you have a substantiated history of violence in any context as an adult?

Yes No

5. Do you have a substantiated history of violence within the family?

Yes No

6. Do you have a substantiated history of abuse or neglect toward any child?

Yes No

7. Do you have a substantiated history of exposing the child or children to negative words, actions, or expressed emotions about the other parent?

Yes No

8. Does the child or children freely, persistently, and vehemently refuse contact with the “out” parent?

Yes No

Briefly describe the magnitude, longevity, and emotion of the child or children’s objection

9. Are you unable to communicate with your co-parent proactively and constructively?

Yes No

10. Do you have very different parenting practices from your co-parent?

Yes No

Specify

11. Is your child or one of your children diagnosed with a serious mental health, physical health, or educational impairment?

Yes No

12. Do you have a substantiated (past or present) substance addiction or behavioral dependency (e.g., drugs, alcohol, gambling, video activities, sex, shopping, etc.)?

Yes No

13. Has your child/children already participated in one or more failed “reunification” therapies?

Yes No

14. Do you have a child by another partner who is resisting/refusing contact with his/her other parent?

Yes No

Part II: Screening Questionnaire for Domestic Abuse/Intimate Partner Violence

1. How comfortable are you interacting with your co-parent?

a. Do you have any concerns, fears or anxieties that I should be aware of?

b. What worries you most?

2. When you look back over time, how were practical, everyday decisions made in the relationship you’ve had with your co-parent?

a. How did you arrive at that arrangement?

b. Are you comfortable with that?

c. What happened when disagreements arose?

3. Is there anything that gets in your way of doing the things you want or need to do in your daily life?

Yes No

If yes, please describe using the examples below.

a. Managing your daily affairs

b. Meeting your basic needs

c. Meeting the basic needs of the children

d. Fulfilling your everyday responsibilities

e. Making your own decisions

f. Interacting with other people

4. Has there ever been any physical violence between you and your co-parent? If yes, please describe.

5. Have you ever felt so ashamed, humiliated, embarrassed or fearful by something you or your co- parent said or did to the other that you didn’t want anyone else to know about it? If yes, please describe what that was like for you (without revealing specifics).

6. Have you or your co-parent ever forced the other to do sexual things the other didn’t want to do, or insisted on having sex when the other didn’t want to? If yes, please describe.

7. Have you or your co-parent ever been concerned that the other was going to physically or psychologically harm the other, the children, or pets? If yes, please explain.

8. How are parenting time arrangements currently being worked out?

a. How did you arrive at that arrangement?

b. Are you comfortable with that?

c. Any concerns about children or fears for their safety?

Please review the table below on the following page, and check any items that are true for your co-parent.

Physical/Sexual Abuse

Hold, pin, restrain

Kneel on or sit upon

Tie up, bind, gag

Push, shove, shake

Grab

Scratch, pull hair

Shave

Twist arm

Bite

Spit on

Urinate upon

Slap

Hit or punch

Kick or stomp

Strike or throw object

Choke or strangle

Burn

Poke, stab, cut

Withhold food

Withhold medicine

Disable medical equip.

Forced sex

Emotional Abuse

Insult you/put you down

Ridicule you in public

Purposely humiliate you

Play mind games

Intimidate you

Yell or scream at you

Act aggressively to you

Get jealous/possessive

Accuse you of infidelity

Interfere with work/school life

Interfere with social life

Interfere with sleep

Interfere with healthcare/medication

Threaten to kill you or the children

Threaten to kill him/herself

Threaten to harm you or the children

Threaten to harm person you care for

Threaten to harm or kill pets

Destroy things you care for

Threaten you w/ weapon

Put your life in danger

Disable your car

Drive recklessly to scare you

Control of Daily Life

Follow or stalk you

Often check up on

Examine mail/email

Check phone calls

Hack into email

Grill you

Time activities

Use others as spies

Invade privacy

Misuse social media

Physically restrain

Forbid you to leave

Punish you for disobeying

Arrive unannounced

Make unwanted contact

Leave things to scare you

Make you do things you don't want to do

Economic Abuse

Deny money

Refuse to pay bills

Empty bank

Hide assets

Destroy your credit

Deny credit access

Run up debt

Forge papers

Refuse to pass title

Destroy property

Steal your property

Sell your property

Shut off utilities

Fail to pay insurance

Cancel insurance

Cancel credit cards

Refuse to work

Refuse to let you work

Try to get you fired

Hide bills

Hide financial info.

Constantly return to court

Note: This screening questionnaire is based on the work of Ben Garber's "Mending Fences" book as well as the SAFeR screening protocol for IPV.

Your information will be encrypted.

Screening for Parent-Child Relationship Repair (PCRR) Services

Part I. General Screening Questionnaire for PCRR Services

Part II: Screening Questionnaire for Domestic Abuse/Intimate Partner Violence

Please review the table below on the following page, and check any items that are true for your co-parent.

Physical/Sexual Abuse

Emotional Abuse

Control of Daily Life

Economic Abuse

Anderson Psychological Services, LLC