CLIENT INFORMATION FORM
Address Line 2(opt.)
State Zip Code
Date of Birth(mm/dd/yy) Marital Status
Make & Model of Vehicle
License Plate Number State
Driver’s License Number State
Other Parent's Name
How To Contact Him/Her
Have you ever been convicted of a crime?(Y/N)
Felony or Misdemeanor?
Has other parent ever been convicted of a crime?(Y/N)
Please List the Children Involved In Parenting-Time:
Date of Birth(mm/dd/yy) Age Gender(M/F)
Please summarize the events that have initiated supervised or therapeutic parenting-time:
How is your relationship with your child/children at this time?
What outcome or goals do you hope to achieve regarding parenting-time?
Do you have any special concerns for the child/children? Are they having any problems?
Please describe any medical conditions and/or medications that would effect your child/children during parenting-time:
Please provide the following information for other professionals involved:
Child Family Investigator
Guardian Ad Litem
Social Services Caseworker
PLEASE JUST HIT THE BUTTON ONCE-