Get in touch

First name

Last name

Phone

Address

Birthday

Month

Day

Year

Relationship Status: (Married, Divorced, Separated, etc.)

Preferred Communication Language: (If applicable)

Preferred Contact Method: (Phone, Email, Text)

Child 1 Name:

Date of Birth:

Gender:

Current Living Situation (Who does the child live with and how much time spent with each parent):

Special Needs/Medical Conditions (if applicable):

School or Childcare:

Extracurricular Activities/Sports:

Any significant behavioral or emotional challenges?

Child 2 Name:

Date of Birth:

Gender:

Current Living Situation (Who does the child live with and how much time spent with each parent):

Special Needs/Medical Conditions (if applicable):

School or Childcare:

Extracurricular Activities/Sports:

Any significant behavioral or emotional challenges?

Are there any children from outside relationships? If so name and age? What does communication/visitation look like for child and other parent?

Family and Co-Parenting History

How long have you and your co-parent been separated/divorced?:

Have you been involved in any previous mediation or therapy sessions?: (Please explain)

Describe the current co-parenting arrangement (e.g., shared custody, primary custody, visitation rights):

What are the primary challenges you are facing in co-parenting? (e.g., communication, conflict, scheduling, decision-making)

What does each parent feel is their role in the child’s life and care?:

Communication & Conflict

How would you describe the current state of communication between you and your co-parent? (e.g., Respectful, Disrespectful, Limited, Conflicted, Neutral, etc.)

Are there any specific communication barriers you are facing? (e.g., arguing, misunderstandings, lack of cooperation)

Do you currently have a shared parenting plan or agreement? (Yes/No, and please describe it briefly, including any issues with its implementation)

Are there any high-conflict areas in co-parenting that you would like to address? (e.g., school decisions, medical care, family activities, vacation plans, new partners)

Emotional and Psychological Well-Being

How have you and your co-parent been managing the emotional and psychological effects of your separation/divorce?

Is there any history of emotional or physical abuse in your relationship or during co-parenting? (Please specify if any safety concerns exist)

Have either parent had any mental health concerns (e.g., anxiety, depression, anger issues)?

Is there any current therapy or counseling for either parent or the child? Who would you consider to be your support system?