Parent History Questionnaire© | Tracy Riley Counseling

Your Contact Information

Full Name*

Home Phone*

Work Phone*

Other Phone

Fax*

Email Address*

Your Attorney's Contact Information

Attorney Name*

Firm*

Office Phone*

Fax*

Email Address*

Your Case Information

Couple Information

Name of the other parent/litigant*

Names of the children & dates of birth & ages of children involved in this Social Investigation*

Names of any children not involved in this Social Investigation (i.e., stepchildren, adult children)*

When did you first meet the other parent?*

How did you meet him/her?*

What attracted you to him/her?*

How long did you date?*

What was the relationship like when you dated?*

How did you decide to marry/have a committed relationship?*

List the dates that you lived together while not married*

Did you ever marry, if so when?*

How was the marriage/relationship in the early stages?*

List dates of separation during the marriage*

List any notable legal actions related to this case*

Have you filed for divorce? If so when?*

Is the divorce final? If so when?*

List where and when you lived with the other parent*

Over the course of the marriage how did you handle disagreements?*

What were the disagreements about?*

How far did the disagreements go (e.g., yelling, pushing, hitting, threats)?*

Were there financial problems during the marriage? Explain. How were these handled?*

What led up to the end of this relationship?*

Who initiated the divorce/end of this relationship?*

Did you try marriage/couple counseling? If so, discuss how it went, when was it and with whom?*

List other psychological evaluations related to this case*

Why haven’t you and the other parent been able to resolve the parenting plan/time-sharing issue?*

What are the present time-sharing arrangements?*

When did these arrangements begin?*

What do you think about the present parenting plan and time-sharing arrangements?*

How far away does the other parent live from you?*

What is your biggest concern about the other parent?*

What is your biggest concern about the well being of your children?*

Who requested this evaluation?*

Why?*

On a scale of 1 to 10 rate how the level of conflict in your situation is effecting your child(ren) psychologically/emotionally* (10 being most severe)

If your child(ren) could tell you honestly how they feel about what’s going on between their parents,* what three (3) things would they say?

What could you do differently to help your child(ren)?*

How do you think your child(ren) feel when you talk about the other parent?*

How would your friends and family describe you?*

What if the judge said that it would in the child(ren)’s best interests to live mostly with the other parent,* how would you react?

What could you do differently to help with this divorce process?*

Research shows the more conflict between parents getting a divorce causes the most psychological damage in children.* Rate the conflict in your situation form 1 to 10 (10 being extreme conflict)

If left strictly up to you, how would you assign time-sharing and parental responsibility?* Be specific, number of overnights, pick-up times, drop-off times, etc.

Why do you want such a plan?*

What are the downsides of this plan, if any?

Individual Information

Do you belong to any religious groups?* If so, discuss, include your involvement in it.

Is religion an issue in this dispute? If so, how?*

Are there any cultural or ethnic issues in this dispute? If so, how?*

Is personal morality an issue? Is so, how?*

How has the divorce/separation affected you?*

Are there/were there any changes in weight; sleeping; energy level; mood; activities; alcohol consumption; or other interests?* If so, explain.

Describe your dating behavior during the marriage and since separation* (include the number of partners, their sex, how often seen, etc.).

What do the children know about the marital situation/relationship situation and how did they find out?*

If you dated, what do the children know about the person(s) dated?*

Do you have a serious relationship now? If so, discuss it.*

When did you realize the relationship was in trouble?*

List where and when you lived since the divorce/separation*

Give a brief summary of the events that led up to this evaluation*

What do you hope will happen as a result of this evaluation*

List the factors that most strongly support your position*

List where you lived without the other parent; give city, state and dates.*

Describe your present living arrangements,* how long you have lived where you are, the number of moves you’ve made since separation, include names and relationships of everyone who lives with you.

Do you anticipate any moves for you or the other parent in the next six months; year; five years?*

Your Background Information

Your Date of Birth*

Your Place of Birth*

Where did you grow up?*

How many marriages did you have?* List names, dates of marriages and divorces

How many children do you have from previous marriages/relationships?*

Describe your post-separation adjustment.*

Your Parents' Information

Your Mother's Name*

Her Age*

If Deceased, when did she die?

Her Occupation(s)*

Where and when did she work?*

How would you describe her?*

Describe her parenting style*

How often do you see her?*

How often do your children see her?*

While growing up, how did you get along with your mom?*

Your Father’s Name*

His Age*

If Deceased, when did he die?

His Occupation(s)*

Where and when did he work?*

How would you describe him?*

Describe his parenting style*

How often do you see him?*

How often do your children see him?*

While growing up, how did you get along with your dad?*

Your Family Information

Describe your childhood; what was it like growing up?*

How is your relationship with them now?*

How many siblings do you have?*

Their names*

Their ages*

Their Places of Residence*

How did you get along with them growing up?*

How do you get along with them now?*

How often do you see them?*

How often do your children see them?*

List any mental health issues in your family (state what, who, how treated, present condition, etc.).*

List any medical issues in your family (state what, who, disposition status, etc.).*

List any legal issues in your family (state what, who, how treated, present condition, etc.).*

List any substance abuse in issues your family (state what, who, how treated, present condition, etc.).*

List any history of DUI’s.*

How many residences did you live-in growing up?*

Why that many?*

Describe any divorces in your family*

Describe your family,* what are the children like, what is the daily routine, how does your family run, do you have regularly scheduled family meetings, if so when, what do you discuss, do you all sit for dinner, w

Educational Information

Give educational history* (include name of institutions, dates attended, degrees earned and major course of study)

Describe your experiences in school; what was school like for you?*

Describe your academic performance; what did you find relatively easy, hard, etc.?*

Describe your social experience in school;* did you have many friends; fights; disappointments; successes?

Employment Information

Describe your present employment* (name of company, what you do, how long there, current salary, etc.)

Describe your present work schedule.*

Describe prior employment,* give company, position, dates of employment, salary and reason for leaving.

Do you have any plans to leave your present employment?* If so, please discuss.

Physical Health Information

Describe your physical health.*

Describe any physical limitations that you may have.*

List medications that you take and the reason for taking them.*

List any hospitalizations (give reasons and dates).*

If your are under the care of a physician give name, address and telephone.*

Mental Health Information

Describe your mental health.*

Have you ever been hospitalized for a mental/emotion illness?* If so, describe.

If your are under the care of a mental health professional give name, address and telephone.*

Describe any treatment for alcohol or drug abuse; past or present.*

How much alcohol do you drink?*

Describe any significant anger issues that you have.*

Describe any significant social problems/issue that you have.*

Describe any substance abuse history,* (what, how much used, when started, last used, treatments, etc.).

Additional Information

Describe any arrests you’ve had.*

Describe any other legal action taken against you.*

Describe any driver’s license suspensions, cancellations, revocations that you’ve had.*

List any previous marriages or other significant long-term, live-in relationships that you’ve had* (give names and dates)

List any children you have had that are not part of this evaluation* (give names, dates of birth and their living arrangements)

Describe any social supports that you presently have* (who are they, how do they support you)

Describe your home, neighborhood and community*

Other Parent's Information

What do you think the other parent’s biggest concern is about you?*

What do you think the other parent’s biggest concern is regarding the well being of the children?*

Describe any significant anger issues the other parent has*

Describe any significant social problems the other parent has*

Describe any legal problems that you think the other parent has*

Describe any physical or mental health issues that the other parent has*

By signing below, I am attesting that the information I have given above is true and accurate, to the best of my ability.

Signature*

Reset

Date*