Guardian Ad Litem – Parent Questionnaire Parent questionnaire when a Guardian Ad Litem has been appointed. Each Party/Parent will fill out the Questionnaire. The information requested applies to you - not the other parent. I SWEAR that the information I put forth on this form is true and correct to my best knowledge.* I swear Your Name* First Last Name of Guardian Ad Litem appointed to your case* First Last Date submitted* Month Day Year Civil Action Number* Name of the other parent/ party* Email* Confirm Email* Phone*Work PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code List the name, age, and relationship of each person living with you.List every place you have lived for the last 5 years.For each place listed, include the address, dates you lived there and who lived with you and their relationship to you.Are you currently married?* Yes No If yes, the date of the marriage and name of spouse. Place of Employment Job Title Number of hours you work per week? How long have you worked at your current place of employment? Name of Immediate Supervisor Supervisor's PhoneList every place you have worked during the last 3 years.Include start and end date, how many hours you worked per week, name of your position and reason you left each job.Date of Birth* Month Day Year Place of Birth? Do you have a high school diploma or GED?* Yes No Name of the high school attended and graduation date? Technical training(specify type of training, place of training, certificates awarded, dates) College, date of graduation, course of study and degree received. Post Graduate Work Professional Licenses Held Criminal history(please list each arrest, date of arrest, location and disposition)Please list all driving infractions and citations you have received in the past 3 years.Have you ever been investigated by the Department of Family and Children's Services (DFCS)?* Yes No If so, please state the approximate date of the investigation, the reason for the investigation, and the outcome of the investigation.*Please provide the name, address and telephone number of any individual you have seen or are currently seeing for therapy, counseling, psychiatric, or psychological treatment. Are you currently paying child support for any child/children? Yes No If so, please list the child's name and the amount of support paid monthly. If applicable, state your religious affiliation, the name of your church, the frequency with which you attend services and the length of the time that you have been a member. What are your hobbies or interests?What are activities that you and your child/children enjoy together?Date and place of your most recent vacation with your child/children? List your top three qualities as a parent.*List the top three qualities of the other parent.*List three issues you struggle with as a parent OR ways you feel you could improve as a parent.*List any concerns you have about the other parent and his/her abilities as a parent.*How do you most often communicate with the other parent?* Phone Text Email All of the above Other Do you have trouble communicating with the other parent? If yes, what problem occur most often.Do you and the co-parent still live in the same house? If no, who moved out and when? Was the move out agreed upon, voluntary or court-ordered? Please explain and share where and with whom the children have primarily resided.*What type of custody or visitation schedule have the children been following?*Are there any problems with the current custody/visitation schedule? If so, what are the problems? Please explain.*What type of custody/visitation plan do you feel is in the best interest of the child/ren?*In your own words, please list the top three issues you would like the Guardian Ad Litem to investigate.*Please list any specific questions you have for the Guardian Ad Litem.Please provide the following information for your child/children (biological and/or adopted):(a) Date of Birth, (b) Address (c) Grade in School, (d) Name of School Attending, (e) Name of School Attended Last Year, (f) Child's Grade Average, (g) Child's extracurricular activities and interests.Name, address, and phone number of any psychologist, psychiatrist, educational consultant, and/or any other mental health professional who has seen the child/children since the time of the divorce.Please give a detailed reason for this professional contact.Name, address, and phone number of any pediatrician, specialist, and/or dentist who has seen the child/children since birth.Name, address, and phone number of any childcare provider for the child/children as well as the typical childcare schedule.Please describe the current emotional state of your child/children regarding this legal action, to the best of your knowledge Please list the following for each witness that you think the Guardian Ad litem should interview to determine the best interests of your child/children in this proceeding:(a) Name (b) Phone Number (c) Address (d) Email Address (e) Occupation and (f) Relationship to your child.Best phone number and time to contact you* Thank you for your honest answers!If you have any questions, please call The Mediation Center at 912-354-6686 or send an email to firstname.lastname@example.org.