Child Custody Questionnaire

GENERAL BACKGROUND

  1. What is your name:_____________________________________________________________________________________
    l a. What is your date of birth:__________________________________________________________________________
    l b. Where were you born: _____________________________________________________________________________
    I c. What is your social security number:________________________________________________________________
  2. What is your current residence address: _______________________________________________________________
    2 a. How long have you resided at this location:_______________________________________________________
    2 b. What is your current telephone number: Day Evening_____________________________________________
  3. Is this the place where the child would live/ visit with you:_____________________________________________
    3 a. State the street addresses where you have lived for the last five years and the dates you lived at
    each address:____________________________________________________________________________________________
    Address From/ to Dates_________________________________________________________________________________
  4. If the answer to Question 3 is no, state the residence address where the child would live/ visit
    with you and state why it is different than where you currently reside: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    PRIOR CUSTODY LITIGATION
  5. Have you been involved in a previous dispute that resulted in a court hearing regarding the
    children who are the subjects of litigation: _____________________________________________________________
  6. If the answer is yes, state the name and location of the Court which heard the case:_____________________________________________________________________________________________________
  7. If the answer is yes, attach a copy of the Court\’s Order in that case.

    PRIOR SOCIAL SERVICES INVESTIGATIONS
  8. Has the Children & Youth Services, or similar agency of authority ever contacted you, your
    current spouse, the other parent, or any party to this litigation regarding an investigation for allegations of abuse, neglect, or sexual abuse of a child? ______ YES _____NO
  9. If the answer is yes, state the name of the Department, the City/County, and the State where the
    investigation took place:______________________________________________________________________________________________________________________________________________________________________________________________________________
    9 a. If the answer is yes, state what the investigation concluded as to whether the case was founded or unfounded, i.e. what was the outcome of the investigation:______________________________________________________________________________________________________________________________________________________________________________________________________
    9 b. Have any of your children ever been in foster care? ________Yes ______________ No
    9 c. If yes, state the name of the child, the dates the child was in foster care, and the Children &
    Youth Services agency which had custody:
    Name of Child Dates In CYS care CYS Agency
    _______________ _______________ _______________
    _______________ _______________ _______________
    _______________ _______________ _______________

    FAMILY AND HOUSEHOLD MEMBERS
  10. State the names of the children involved in the present Court action:
    Name Relationship to you Sex Birthdate Grade in School
    _______________ _______________ ______ ________________ _______________
    _______________ _______________ ______ ________________ _______________
    _______________ _______________ ______ ________________ _______________
  11. State the names of all persons who reside in your home, both children and adults:
    Name Relationship to you Sex Birthdate Grade in School
    _______________ _______________ ______ ________________ _______________
    _______________ _______________ ______ ________________ _______________
    _______________ _______________ ______ ________________ _______________


    EMPLOYMENT HISTORY
  12. What is the name, address, and telephone number of your current employer:___________________________________________________________________________________________________________________________________________________________________________________________________________
    12 a. How long have you been employed with your current employer:___________________________________________________________________________________________________________________________________________________________________________________________________________
    12 b. What are your work hours:________________________________________________________________________
    12 c. What time do you leave home for work and what time do you return home each day:________________________________________________________________________________________________________________________________________________________________________________________________________________
    12 d. Do you work weekends:___________________________________________________________________________
    12 e. Do you work nights:_______________________________________________________________________________
    12 f. Do you travel on your job or are you on call in the evenings:_____________________________________
    12 g. State the names, addresses and telephone numbers of your employers for the past three years:
    Name of employer Address Telephone Dates of work there
    ____________________ _______________ __________________ _____________________
    ____________________ _______________ __________________ _____________________
    ____________________ _______________ __________________ _____________________
    12 h. What is your current annual income:______________________________________________________________
  13. Describe your educational background:_________________________________________________________________
  14. Describe your job skills including a brief description of the types of work you are capable of
    doing:_______________________________________________________________________________________________________________________________________________________________________________________________________________
  15. Have you served in the U.S. Military: _______ NO_________________________________________________________
    15 a. If so, state the branch of Military and describe the type of work you did for the military:_____________________________________________________________________________________________________________________________________________________________________________________________________________

    CRIMINAL AND TRAFFIC RECORD
  16. Have you ever been convicted of a crime including a traffic offense: _
    16 a. If yes, state the crime: _____________________________________________________________________________
    16 b. If yes, state the name of the Court, City/County, and State where you were convicted:___________________________________________________________________________________________________________________________________________________________________________________________________________

    PHYSICAL HEALTH HISTORY
  17. Describe your current physical health condition:___________________________________________________________________________________________________________________________________________________________________________________________________________
  18. Describe the current health condition of the other parties in this case:_______________________________________________________________________________________________________________________________________________________________________________________________________________
  19. Describe the current health condition of the children who are the subjects of this litigation:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
    19 a. Do the children have any special health problems such as allergies, hyperactivity, etc. which one
    parent has more background or better skills to deal with: ______ NO ___________________________________
    If yes, explain: ______________________________________________________________________________________________________________________________________________________________________________________________________________________
    19 b. Name the children\’s doctors and dentist:______________________________________________________________________________________________________________________________________________________________________________________________________________
    19 c. Have you ever met with the children\’s doctors or taken the children to their doctors for regular
    checkups or during illnesses: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
    19 d. Do you believe the children have received adequate health care and routine wellness visits: _ __________________________________________________________________________________________________
    19 e. If not, describe what you believe the deficiencies to be: ___ _
    19 f. Who has been the person primarily responsible for taking the children to the doctor and dentist in the past: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  20. Do you claim that the physical health of a parent or child is an issue in this litigation: ___ NO_________
    20a. If yes, explain why: ______________________________________________________________________________________________________________________________________________________________________________________________________________________
  21. Do you have health insurance that covers the children: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
    21 a. State the cost of the insurance ( do not include the cost for you, only the cost attributable to the children and attach a letter from your employer or health care provider to prove the cost)
    21 b. State the name of the health insurance company, the address and policy number:

    MENTAL HEALTH HISTORY
  22. Describe your current mental health condition including drug and alcohol abuse: _
    22 a. Have you ever been treated by a psychologist, psychiatrist, or mental health practitioner for a mental health, drug, or alcohol problem: _______________________________________________________________
    22 b. If yes, state the name and address of the person providing treatment:
    22 c. State the date of whom treatment: ________________________________________________________________
    22 d. State the diagnosis you were given: _______________________________________________________________
    22 e. State the medication you were prescribed: ________________________________________________________
    22 f. Are you currently being treated by a psychologist, psychiatrist, or mental health practitioner for a mental health, drug, or alcohol problem? NO ________________________________________________________
    If yes, state the name and address of the person providing treatment: ________________________________
    22 h. Are you currently taking any type of medication as result of such treatment: ___________________________________________________________________________________________________________If yes, what is the medication:___________________________________________________________________________
    22 j. Have you ever been hospitalized for a mental health problem, including a drug or alcohol problem: ________________________________________________________________________________________________
    22 k. Has anyone ever suggested or refe1Ted you for evaluation on treatment for alcohol or drug
    problems:________________________________________________________________________________________________
    a. If so, did you have a such evaluation or treatment:___________________________________________________
    b. Did you complete such an evaluation or treatment: :________________________________________________
    c. Did you decline such an evaluation or treatment: :___________________________________________________
  23. Describe the mental health condition of each child who is the subject of this litigation:_______________
    23 a. Have any of the children who are subject of this li6gation ever been treated by a psychologist, psychiatrist, or mental health practitioner for a mental health, drug, or alcohol problem:_________________________________________________________________________________________________
    23 b. If yes, state the name and address of the person providing treatment and the name of the child
    receiving treatment: _____________________________________________________________________________________
    23 c. State the date of the child\’s treatment: :___________________________________________________________
    23 d. State the diagnosis the child was given: :__________________________________________________________
    23 e. State the medication prescribed for the child::_____________________________________________________
    23 f. Are any of the children who are subject to this litigation currently being treated by a psychologist, psychiatrist, or mental health practitioner for a mental health problem or a drug or alcohol problem: ______________________________________________________________________________________________________________________________________________________________________________________________________________________
    23 g. If yes, state the name and address of the person providing treatment: __________________________________________________________________________________________________________
    23 h. Are any of the children who are the subject of this litigation currently taking any type of
    medication prescribed as a result of this treatment: ____________________________________________________
    23 i. If yes, what is the medication: ______________________________________________________________________
    23 j. Have any of the children who are the subject of this litigation ever been hospitalized for a mental health problem, including a drug or alcohol problem: __________________________________________
    23k. If yes, state where the hospitalization occurred and when it occurred:_____________________________
  24. Describe the mental health condition of the other party to this litigation, including drug and
    alcohol abuse: ___________________________________________________________________________________________
    24 a. Has the other party to this litigation ever been treated by a psychologist, psychiatrist, or mental
    health practitioner for a mental health, drug, or alcohol problem:______________________________________
    24 b. If yes, state the name and address of the person providing treatment::___________________________
    24 c. State the date of the treatment rendered to the other patty in this litigation:_____________________
    24 d. State the diagnosis given to the other patty in this litigation: ____________________________________
    24 e. State the medication prescribed to the other party in this litigation if you know: ________________
    24 f. Is the other party in this litigation cu1Tently being treated by a psychologist, psychiatrist, or other mental health practitioner for a mental health, drug, or alcohol problem:________________________
    24 g If yes, state the name and address of the person providing treatment:
    24 h. Has the other party to this litigation ever been hospitalized for a mental health problem,
    including drug or alcohol problem. _____________________________________________________________________
    24 i. If yes, state where the hospitalization occurred and when it occurred: :____________________________
  25. Describe your usage of alcohol, prescription, and nonprescription drugs:
  26. State the usage of alcohol, prescription, and none prescription drugs by the other party to this
    litigation: :_______________________________________________________________________________________________

    MARITAL HISTORY
  27. What is the name of your current spouse: ______________________________________________________________
  28. Do you and your current spouse live together:__________________________________________________________
  29. Have you ever been married before: ____________________________________________________________________ If yes, how many times and to whom: __________________________________________________________________
  30. Do you have children from prior marriages or relationships:____________________________________________
    30 a. Describe the relationship between these other children and the children whose custody/visitation is before the Court:___________________________________________________________________
  31. If these children have not already been named in response to Question 11 state their names and
    ages here: _______________________________________________________________________________________________
  32. Who has custody:________________________________________________________________________________________
    32 a. If you don\’t have custody, explain what pa1iial custody or visitation you have with the other
    child(ren)?: ______________________________________________________________________________________________
    32 b. Is there a custody Order or written agreement?: __________________________________________________
  33. If there has been custody litigation regarding these children, state the name and address of the
    Court in which the litigation took place: ________________________________________________________________
  34. Attach a copy of the Court Order or written agreement regarding custody of these children.

    NEEDS OF THE CHILDREN
  35. State whether any of the children who are the subject of this litigation have any special needs
    (reflecting either a physical or emotional need: ________________________________________________________
    35 a. If yes, state which child or children and state the exact nature of the special need:_______________
    35 b. State which party to the litigation can better provide for the special needs of the child and why:______________________________________________________________________________________________________
    35 c. Describe the needs of each child who is the subject of this litigation and describe other important relationships each child has, including but not limited to the other child\’s relationship with brothers and sisters; friends and peers; and extended family members. State which person as custodian can better meet the needs and why/how :_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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