Homework – History with Co Parent & Childhood Experience Date* MM slash DD slash YYYY Demographic DataYour Name* First Last Are you the Plaintiff or Defendant?* Plaintiff Defendant Gender* Male Female Age* 0-19 20-34 35-54 55-64 65-74 75 or Above Ethnicity* Black/African American Asian White Hispanic Native American Multi Other Annual 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 - $100,000 $100,000 - $150,000 $150,00 - $200,00 $200,000 - $300,000 $300,00 - $400,000 $400,000 - $500,000 $500,000+ Highest Level of Education* Some High School GED Graduated High School Graduated Tech School AA College Degree Master's Degree Ph.D. Professional Degree (J.D.; M.D., etc.) What county do you live in?*ChathamLibertyEffinghamBryanOtherWhat is your zip code?*ChathamLibertyEffinghamBryanOtherDo you live in the Savannah city limits?* Yes No Not sure How many children do you have with your co-parent?*Please enter a number from 1 to 10.Are/were you married to your co-parent?* Yes No What number marriage is/was this with your current co-parent?* 1st 2nd 3rd 4th 5 or more We are not married How long were you married to your current co-parent?*Please enter a number from 0 to 100.How long did you date your co-parent before getting married or having a child (if not married)?*Please enter a number from 0 to 100.Did you live with your co-parent before getting married or having a baby (if not married)?*Please enter a number from 0 to 100.If you have other children, how many other children do you have?*Please enter a number from 0 to 10.How many times have you been married?*Please enter a number from 0 to 20.How many times have you been divorced?*Please enter a number from 0 to 20.Enter the number of times you have filed an action against your co-parent.*Enter the number of times your co-parent has filed a legal action against you.* Have you ever been investigated by the Department of Family & Children Services? If yes, list the date(s) and the outcome(s) of the investigation. If no, enter no.*TherapyAre you children currently in therapy?*YesNoIf in therapy, enter name of all therapists seen. Enter N/A if doesn't apply.* Enter average number of months one or more of your children have seen a therapist. Enter N/A if doesn't apply.*Are you currently in therapy?*YesNoIf in therapy, enter name of all therapists seen. Enter N/A if doesn't apply.* Estimated number of months you've been in therapy? Enter N/A if doesn't apply.*Co-parent DataList your three best qualities as a parent.#1* #2* #3* List your co-parent’s three best qualities.#1* #2* #3* List three areas you struggle with when parenting your child/ren.#1* #2* #3* List your three top concerns about your co-parent’s parenting abilities.#1* #2* #3* List your three main concerns about your children.#1* #2* #3* Rate the communication between you and your co-parent? (with one being very easy to communicate with each other and 10 being no communication)*Please enter a number from 1 to 10.How often do you communicate with your co-parent?*NeverRarelyAs issues ariseOnce a MonthOnce a WeekSeveral times per weekDailyMultiple times per dayWhat is the main form of communication you use with the other parent? Mark the TOP THREE methods you use most often.* Email Text Family Wizard By Cell Phone while our children are home By Cell Phone when are children are not home Leaving voicemail messages on his/her cell phone Calling co-parent at work Through my attorney Sending messages verbal or written through our children Other If you selected "other" in the question above, please share your main form of communication. Have these forms of communication worked?* Yes No Would you like to change the way you communicate with your co-parent?* Yes No What are the main issues, situations or events that cause conflict between you and your co-parent?#1* #2* #3* Select the TOP TWO responses you use to handle disagreements with your co-parent?* Call my attorney File a lawsuit Get your co-parent to see you side Negotiate and stay child-focused Argue unproductively Other If you selected "other" in the question above, please share your main form of communication. How would you describe your relationship with your co-parent at this time?*Extremely hostileHostileModerately angryAvoidant/coldNeutralCivilFriendlyRate your stress level at this time? (1 being low and 10 being high)*Please enter a number from 1 to 10.List the top three ways you handle your stress levels on a daily basis.#1* #2* #3* How do you feel/act when you interact with your co-parent? Select the TOP THREE.* Out of control Angry Frustrated Don’t feel heard Sad and/or upset Have a difficult time with impulse control Yell and Scream Have hostile tone-of-voice and/or body language Defensive Use sarcasm during conversations/discussions Hang up/walk away in an attempt to control anger Hang up/walk away to set boundaries when other parent is verbally abusive Listen and respond appropriately Other If you selected "other" in the question above, please share your main form of communication. List three ways you decompress after a disagreement/argument with your co-parent.#1* #2* #3* List your top three hobbies or outside interests and how often you partake in these activities. If none, insert none.#1* #2* #3* Childhood ExperienceAre your parents married?*YesNoSeparatedNever MarriedHiddenIf your parents are divorced or separated, how old were you when they divorced or separated? Enter N/A if doesn't apply.*Was there a custody battle?* Yes No N/A Which parent did you live with primarily?*N/A, I lived with both parents growing upI lived primarily with my MomI lived primarily with my DadI grew up with other guardiansDo you feel you had enough time with each parent?*N/A my parents lived together.Yes, I had enough time with both parentsNo, I didn't see my Mom enoughNo, I didn't see my Dad enoughNo, I didn't see my Mom and Dad enoughDo your parents have a good relationship with one another now?* Yes No Did both your parents attend your school or sporting events?* Yes No If no, did it bother you? (Enter N/A if doesn't apply)* Yes No How many times was your mother married?*How many times was your father married?*Enter number of step-siblings. If none, enter 0.*Enter number of half-siblings. If none, enter 0.*How did your parents’ divorce or living apart situation affect you? Select the TOP FIVE.* N/A my parents lived together It was traumatic My parents’ divorce was high conflict A guardian ad litem was appointed in their divorce My parents put me in the middle I feel like I did not get to see my mom enough I feel like I did not get to see my dad enough I feel like I did not get to see both parents enough I did not like the custody schedule The custody schedule was disruptive I liked the custody schedule I felt like the divorce was my fault I was depressed I rebelled and got into trouble It affected my future romantic relationships It affected my school work It affected my self-esteem It affected my relationship with my mom. It affected my relationship with my dad. It affected my relationship with both parents. My mom bad mouthed my dad. My dad bad mouthed my mom. My mom did not let me talk about my dad. My dad would not let me talk about my mom. My parents made me feel like I could not love them both. I do not want to make the same mistakes my parents did during their divorce. It hurt me when either my mom insulted or complained about my dad. It hurt me when either my mom insulted or complained about my dad. My parents did their best to minimize the effect the divorce had on me. My parents worked together to make sure I got to see them both. My parent’s divorce was civil. My parents worked together to make sure my needs were met. My parents worked better in separate homes. My parents were/are friends. 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 ARE BOUND BY CONFIDENTIALITY AND CAN NOT BE SUBPOENAED TO COURT TO TESTIFY IN YOUR CASE.* 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. Δ