Children 1st Confidential Intake Form Today's Date* MM slash DD slash YYYY Please select the month you're registering for (class will be held 4 consecutive Saturdays during the month):April/May 2022: April 30, May 7, 14 &21August 2022: Aug 6, 13, 20 & 27Oct/Nov 2022: Oct 29, Nov 5, 12 & 19Your Full Name* First Last Your Cell phone number* Your Email address* Your Co-parent's Name* First Last Your co-parent's email address* Your Co-Parent's cell phone number* County you live in* Your Zip Code* Your Attorney's 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?* Divorce Legitimation Modification Action Contempt Action Modification & contempt actions How 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+ Who has paid all or part of your attorney fees for this current action?* I have - 100% My parents Friends Other family members I paid some & family/friends paid some Do you owe your attorney fees for this current action? If yes, how much?* Yes No 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+ Who has paid all or part of your attorney fees for previous actions?* I have - 100% My parents Friends Other family members I paid sum & family/friends paid sum If custody was decided by the Judge (in a previous action or at a temporary hearing in the current action), did you agree with the Judge's decision?* Yes No, the Judge got custody wrong! Somewhat NA - no hearing has been held yet. What type of custody arrangement are you asking for in your current lawsuit?* Primary Physical custody & co-parent gets visitation Joint Physical Custody - 50/50 arrangement Visitation & my co-parent gets primary physical custody Primary Physical custody & co-parent gets limited visitation Sole custody & co-parent gets supervised visitation Sole Custody & co-parent has not contact with the children at all Other What type of custody arrangement is your co-parent asking for in your current lawsuit?* Primary Physical custody & I get visitation Joint Physical Custody - 50/50 arrangement Visitation & I get primary physical custody Primary Physical custody & I get limited visitation Sole custody & I get supervised visitation Sole Custody & I get no contact with the children at all Other Are you upset or annoyed about having to attend this class?* Very Annoyed Somewhat annoyed Didn't bother me Open to attending the class Happy to attend Do you think/feel your co-parent is high conflict?* Yes No Somewhat Do you think/feel you are a high conflict parent?* Yes No Somewhat Do you think/feel your relationship with your co-parent is high conflict?* Yes No Somewhat Do you view/feel this class as a punsihment?* Yes No Somewhat Did you think/feel that you should have to attend this class?* Yes No Somewhat Did you think/feel that your co-parent should have to attend this class?* Yes No Somewhat Do you think/feel you have a role/ part in the conflict with your co-parent?* Yes No Somewhat Are you willing to put your Children 1st and learn new ways to interact with your co-parent for the benefit of your child/ren?* Yes Somewhat No Do you think it is in your child/ren's best interest to have both parents involved in their lives?* Yes No Somewhat Co-parent should have limited & controlled access to our children My co-parent doesn't deserve contact with our children How 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.Were you court-ordered to this class or is it voluntary?* Court-Ordered Voluntary 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. Δ