Children 1st Confidential Intake Form

Step One: Complete the Children 1st Confidential Intake Form

Please complete the following form. Make sure all required fields have an answer and click submit. Next, on the Children 1st page you will complete Step Two and pay for the class per the Order signed by the Judge. Once our team receives the intake form and payment, you will receive additional information to attend the class.

Today's Date*
MM slash DD slash YYYY
Email
Please select the month you're registering for (class will be held 4 consecutive Saturdays during the month):
Your Full Name*
First Last
Your Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Cell phone number*
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.

Step One: Complete the Children 1st Confidential Intake Form

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Step One: Complete the Children 1st Confidential Intake Form

Contact Us

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