Children 1st Confidential Intake Form Date* Date Format: MM slash DD slash YYYY Please select the month you're registering for (class will be held 4 consecutive Saturdays during the month):August 2020October 2020Your Full Name* First Last Cell phone number*Email address*Your Attorney's Name*Full Name of Co-parent*Co-parent's Attorney Name*Civil Action #*Judge*Is there a Guardian ad Litem assigned to your case? If yes, please enter their name.What type of action is currently pending?*DivorceLegitimationModification ActionContempt ActionModification & contempt actionsHow much money have you spent, owe or expect to spend in attorneys fees in this current action?*$1,000 - $5,000$6,000 - $10,000$11,000 - $15,000$16,000 - $20,000$20,000 - $25,000$25,000 - $30,000$35,000 - $45,000$50,000-$75,000$75,000 - $100,000$100,000+How much money have you spent or owe in attorneys fees in previous actions with your co-parent?*$1,000 - $5,000$6,000 - $10,000$11,000 - $15,000$16,000 - $20,000$20,000 - $25,000$25,000 - $30,000$35,000 - $45,000$50,000-$75,000$75,000 - $100,000$100,000+If the current action is a modification or contempt action, did you settle the original action or was custody decided by the Judge?*Settled itJudge DecidedN/A - current action is the 1st action for custodyIf custody (in the above-referenced action) was decided by the Judge, did you agree with the Judge's decision?*YesNo, the Judge got custody wrong!SomewhatIf the current action is a divorce or legitimation action and you have had a hearing, do you agree with the Judge's ruling on custody?*No, the Judge got it wrong!YesSomewhatN/A - current action is a modification/contemptGender*MaleFemaleAge*0-1920-3435-5455-6465-7475 or AboveEthnicity*Black/African AmericanAsianWhiteHispanicNative AmericanMultiOtherAnnual Income Before Taxes*$0 - $9,999$10,000 - 14,999$15,000 - 24,999$25,000 - $34,999$35,000 - $49,999$50,000 - $74,999$75,000 - $150,000$150,00 - $250,000$250,000 - $500,000$500,000+What county do you live in?*ChathamLibertyEffinghamBryanOtherDo you live in the Savannah city limits?*YesNoWhat type of custody arrangement are you asking for in your current lawsuit?*Primary Physical custody & co-parent gets visitationJoint Physical Custody - 50/50 arrangementVisitation & my co-parent gets primary physical custodyPrimary Physical custody & co-parent gets limited visitationSole custody & co-parent gets supervised visitationSole Custody & co-parent has not contact with the children at allOtherWhat type of custody arrangement is your co-parent asking for in your current lawsuit?*Primary Physical custody & I get visitationJoint Physical Custody - 50/50 arrangementVisitation & I get primary physical custodyPrimary Physical custody & I get limited visitationSole custody & I get supervised visitationSole Custody & I get no contact with the children at allOtherAre you upset or annoyed about having to attend this class?*Very AnnoyedSomewhat annoyedDidn't bother meOpen to attending the classHappy to attendDo you think/feel your co-parent is high conflict?*YesNoSomewhatDo you think/feel you are a high conflict parent?*YesNoSomewhatDo you think/feel your relationship with your co-parent is high conflict?*YesNoSomewhatDo you view/feel this class as a punsihment?*YesNoSomewhatDid you think/feel that you should have to attend this class?*YesNoSomewhatDid you think/feel that your co-parent should have to attend this class?*YesNoSomewhatDo you think/feel you have a role/ part in the conflict with your co-parent?*YesNoSomewhatAre you willing to put your Children 1st and learn new ways to interact with your co-parent for the benefit of your child/ren?*YesSomewhatNoDo you think it is in your child/ren's best interest to have both parents involved in their lives?*YesNoSomewhatCo-parent should have limited & controlled access to our childrenMy co-parent doesn't deserve contact with our childrenHow many children do you have with your co-parent?*Please enter a number from 1 to 10.If you have other children, how many other children do you have?Please enter a number from 1 to 10.CONFIDENTIALITY* I understand and acknowledge agreement to class confidentiality and understand class participants, Mediation Center staff, and instructors are bound by confidentiality and cannot be subpoenaed. CHILDREN 1ST: HIGH CONFLICT PARENTING CLASS IS A CONFIDENTIAL COURT-ORDERED CLASS. EVERYTHING SAID IN THE CLASS IS CONFIDENTIAL AND CAN NOT BE USED IN COURT. THE INSTRUCTORS AND OTHER PARENTS IN THE CLASS ARE BOUND BY CONFIDENTIALITY AND CAN NOT BE SUBPOENAED TO COURT TO TESTIFY IN YOUR CASE. ANY INFORMATION PROVIDED TO THE MEDIATION CENTER STAFF AND/OR DIRECTORS OUTSIDE OF THE CLASSROOM IS NOT CONFIDENTIAL AND MAY BE USED AT A SHOW CAUSE HEARING IF A PARENT FAILS TO COMPLY WITH THE CLASS REQUIREMENTS.