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Name
Email
Address
Telephone
How many children are involved in this matter
Provide the first name and age of each child
-+
If you have a case and know the Document number* of your case provide the Docket Number
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Country USA
Jurisdiction of your case
If you have a lawyer what is the name of your lawyer now
What law firm is your lawyer associated with
If you know the name of the lawyer that is or was last representing your former spouse/partner tell us their name
Name of their law firm
Are you going through a separation YesNo
Are you going through a divorce now YesNo
Is this a post-divorce matter YesNo
If you have any schedule court dates coming up, what is the date of the next hearing in court
Tell us the reason for this court hearing
*If you have a copy of the most recent court order in your case that pertains to time sharing ( physical custody ) with the children; and parental decision making authority ( legal custody ), please send a copy of this court order to GOLDBERG & ASSOCIATES, attaching It to an email at: info@adolescentdissociativedisorders.com
Are you remarried or living with a significant other that comes In contact with your children now YesNo
Is your former spouse remarried or living with a significant other that comes into contact with your children now YesNo
What is your Occupation or Profession
What is the Occupation or Profession of your former spouse or partner
If you have a new spouse or significant other do they have any minor children that live with you YesNo
Does your former spouse have a new spouse or significant other who has minor children that live with them YesNo
What is the Occupation or Profession of your new spouse or significant other
What is the Occupation or Profession of the new spouse or the significant other living with your former spouse / partner
Are any of the following professionals currently engaged in your case at this time:
A child custody evaluator YesNo
A Guardian ad litem YesNo
A Parenting Coordinator YesNo
Other
Describe the nature of your current relationship with each child
Has there been any of the following problems associated with your Case:
Domestic Violence Evidence found against you YesNo
Child Abuse confirmed by Child Protective Services involving you YesNo
Substance Abuse confirmed involving you YesNo
Allegations of domestic violence YesNo
Allegations of substance abuse YesNo
Allegations of child abuse
If any of your children are now seeing a mental health professional for individual counselling, tell us which child/ren
If any of your children are not seeing a psychiatrist, tell us which children
Is there a diagnosis assigned to any of your children. If there is and If you know what diagnosis has been applied - tell us the diagnosis and tell us the name(s) of the children the diagnosis applies to
Who is the Policyholder for the children’s insurance plan
Have any of your children had excessive school absences and early School dismissals in the last year, if yes tell us which child this does Apply to
Do any of your children have a history of somatic complaints ( i.,e, headaches or stomach aches..) If so, which children does this also apply to
Do your children have any history of self-harming behaviour ( I.e.cutting, scratching, burning, head banging, etc.) if this applies tell Us which child/ren it applies to
