Name

Your Street Address, Town/City, Postal Code

Email Address

Phone Number

Preferred method of contact Preferred method of contactPhoneEmail

Occupation

List Child(ren): Name (DOB); Name (DOB)

Which child(ren) will be participating in reunificaiton?

Name of Lawyer

Who were you referred by?

Name of Other Parent

Other Parent's Street Address, Town/City, Postal Code

Other Parent's Email Address

Other Parent's Phone Number

Other Parent's Occupation

Other Parent's Lawyer

Date of Marriage/Start of Relationship

Date of Separation

Do you have a signed Parenting Plan? Do you have a signed Parenting Plan?YesNoOther

If YES, when did the child(ren) last participate in a parenting schedule?

Please describe the current living arrangements of the child(ren):

Describe the level of contact the child(ren) has with the non-resident parent:

Describe how you and your former partner are communicating about the children:

Describe the factors that led to the breakdown in the parent/child relationship:

What are your biggest concerns for your children right now?

What are your goals for reunification therapy?

Please share any additional concerns or comments: