Minor's Counsel First Steps - Questionnaire

Instructions:

- If you do not read English well, please call the office!

- If you need more space, add additional sheets of paper.

THANK YOU FOR HELPING ME UNDERSTAND YOUR CHILD’S CASE BETTER BY PROVIDING ME WITH THIS INFORMATION. IF YOU HAVE QUESTIONS, PLEASE CONTACT MY OFFICE. Christine Gille.

YOUR PERSONAL INFORMATION:

Case Name_______________________ Case Number _______________________

Your Other

Name_______________________ Names you use __________________

Current Address____________________________ Own? Rent?__________

Current Employer________________ Former Employer________________

Visa or

Date of Birth__________ Social Security #__________ Green Card #__________

Driver’s License #, State____________ (Please give me a copy of your license.)

If no license, an I.D. you show for public transportation ________ (Copy please)

Vehicle License #, State______________________

** For Restraining Orders, monitored visitation, or if one side has no visitation with the child(ren), please describe problem, give the date of any court orders, and give the name and contact info of any monitor:

_______________________

YOUR CHILD’S INFORMATION:

Name of Child #1 ___________________ Date of Birth________________

Social Security # of Child #1 ___________________

Brief Description of Child #1 ______________________________________

Is a child of yours a special needs child? If yes, describe the special needs and how your child copes
_______________

Summary of the conflict that created the need for an attorney for your child or children.

_______________________________

Do you suspect/have proof that there is domestic violence, substance abuse, neglect, sexual abuse or mental illness in either parent’s family that has impacted this child? Briefly describe your suspicions and proof:

___________________________

Do you suspect or have proof that the child(ren) may have temperament or mental health issues, such as anxiety or depression, chronic illness, substance abuse issues, frequent trouble at school, or other issues that are affecting the child’s behavior or well-being? Briefly describe your suspicions and proof:

___________________________

**

Every family is different. In your family who primarily did/does the following things for the child?

1. Who feeds the child meals?_____________________________________

2. Who takes care of most of the grooming issues?____________________

3. Who is the parent who takes care of clothing?_____________________

4. Who schedules health care appointments?________________________

5. Who arranges social activities for the child?_______________________

6. Who arranges after school care or preschool? _____________________

7. Who arranges social activities, sports, music, other? ­­­_______________

8. Who is there when the child goes to sleep/wakes up?_______________

9. Who taught toilet training, manners, respect, etc.?________________

10. Who educates the child about the family: Customs, traditions? _______

11. Who teaches basic skills; reading, writing, or math? ______________

12. Who provides financially for the child?__________________________

13. Who comforts the child he or she is sad or angry?_________________

14. Who takes the child to school/takes home?______________________

Schedule and School Information:

Please provide copies of report cards or preschool progress notes for two years.

Current School or Preschool:___________________________

Address___________________________ Phone No._____________

Previous School or Preschool_____________________________

Address___________________________ Phone No.___________

Current Daycare or After-School Provider____________________

Address___________________________ Phone No._________

Previous Daycare or After-School Provider _________________

Address___________________________ Phone No.________

Check one. This school-age child attends school: _______
”Year-Round.” _____
Traditional schedule with summer break. ______
Is home-schooled. ________

Independent study. _______
Child dropped out of school.

Current Week Day (school-time) Schedule: ___________________

Weekend Schedule & Activities: _____________

Summer or Between Term Schedule:

______________________________

Professional Information:

Child’s Pediatrician or Other Doctor _________________________

Address_____________________________ Phone No._________

______________________________________________________

Child’s Dentist _________________________________________

Address_____________________________ Phone No.________

Child’s Orthodontist ____________________________________

Address_____________________________ Phone No._______

Child’s Mental Health Professional ________________________

Address_____________________________ Phone No._________

Child’s Other Consulting Professional _______________________

Address_____________________________ Phone No._________

Your Own Mental Health Professional ______________________

Address_____________________________ Phone No._________

OTHER WITNESSES WITH IMPORTANT INFORMATION: List names, contact numbers and a brief description of what they saw. Have the most knowledgeable witnesses call my office for an appointment.

________________________________

More Information about your child or children

Leisure Activities:

Does your child have any regular scheduled activities such as sports or music? Does any activity cause conflict with the child’s other parent?

____________________________________

Pets: If you have pets, describe. Explain whether these animals cause conflict with the other parent.

____________________________________

Special Talents of Child:

________________________________

Chores: What responsibilities does your child have while in your custody?

____________________________________

Activities, Belongings What activities or belongings make your child happiest? Do any of these cause conflicts with the other parent?

_______________________________

Religion: Does your child ever attend a religious institution? Does your choice of religion or no religion cause conflict with the child’s other parent?

_____________________________________

Strong Negative Emotions

Does your child react with strong negative emotions to any event, person or other things? If so, describe:

_________________________________

**

More Information About You, the Parent

Your New Relationship: Do you have a new intimate relationship? Give name, address & phone number. Please have him or her contact me as a witness. If a new relationship you now have seems to be causing conflict for the child or the other parent, briefly describe the conflict and what may be done to correct.

_________________________________

Others who live in your home: Please list name, contact #, and relationship, including any children. List other languages spoken in the home. List those who know most about any conflicts affecting the child first.

______________________________

Citizenship Status

If you are not a U.S. Citizen, does your citizenship status cause conflict? Describe: ______________________________

Your Legal & Criminal Record If you have had any other Divorces, Parentage or Paternity cases, Guardianship, Adoption, Child Support, Domestic Violence Restraining Orders or Criminal cases, please provide the case numbers, the County/State and the status of the cases. ________________________________

MOVE-AWAY INFORMATION:

IF one or both parents have moved, or are deciding whether to move away from Los Angeles County, please give a brief description of any compromises that can be made about child custody and what issues have arisen or will arise based on the distance between the two parents’ homes. Please also describe how the child will stay in touch with the other parent in the long run, and what parenting plan seems most logical for the next year to three years. _______

I, declare under penalty of perjury under the laws of the State of California that the above information is true and correct.

Your Signature____________________________ Date________

Print your name________________________________________

THANK YOU for your help. Christine Gille

You may only obtain a Minor's Counsel by court order. If you need a curriculum vitae, please contact my office at (626) 340-0955. We handle cases filed at courthouses located in Pasadena, Los Angeles, Van Nuys, Burbank (now moved to Pasadena) and San Fernando. Certified Family Law Specialist with full legal team. Special emphasis on high conflict custody issues.