Parenting Consulting Information Form

Date

Parent Identifying Information:

Name

Relationship to child(ren)

Age

Date of Birth

Address

Contact information: (H)

(W)

(C)

Place of Birth

Religion

Observant

Occupation and Company

Full time

Part time

Average hours per week

(M/T/W/TH/F/S/S)

Please elaborate as needed e.g. overnights, multiple jobs, weekends, extended travel requirements, etc.

Education/Degree(s)

Attorney

Firm

Address

Contact information: (W)

Co-parenting Relationship History:

What was the duration of your marriage / relationship with the other party (provide broad dates)?

Are you fearful of the other parent for any reason?

Yes No

If yes, please explain

Is there a history of domestic violence?

Yes No

Are there any orders for protection (OFP)?

Yes No

If yes, please explain

Children's Information:

Please list the individuals that you reside with, and their relationship to you:

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Are you currently in a relationship?

Yes No

If yes, does that individual have contact with the children?

Yes No

Do you have children from any other relationships?

Yes No

If yes, please provide their name(s) and age(s):

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Children (shared children with coparent named in the PC Appointment Order):

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Parenting Time:

Current legal and physical custody of children impacted by this process

Please indicate when you have scheduled time with the child(ren):

Week 1

MON

TUE

WED

THU

FRI

SAT

SUN

Week 2

MON

TUE

WED

THU

FRI

SAT

SUN

Week 3

MON

TUE

WED

THU

FRI

SAT

SUN

Week 4

MON

TUE

WED

THU

FRI

SAT

SUN

Parenting plan implementation problems/concerns:

Do you need any specific assistance with your parenting?

Yes No

If yes, specify

Current Co-parenting Information:

Do you have any concerns about your coparent's parenting?

Yes No

If yes, specify

How would you rate the current relationship with the other parent?

Good Fair Poor High Conflict

What impact has this relationship had on the children?

Significant Some Minor Minimal to no impact

What changes do you think could improve the situation?

Future co-parenting goals

Any additional concerns

Professional Consultation:

Previous and current collateral sources (e.g. psychologists, social workers, psychiatrists, pediatricians, etc.).

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Anderson Psychological Services, LLC

Phone: 612-374-2400, Fax: 651-501-2400, Email: deborah@andersonpsychology.com
andersonpsychology.com
Woodhill Office Park 2155 Woodlane Drive, Suite 201, Woodbury, MN, 55125