Coparenting Form for post divorce conflict resolution

This questionnaire will be submitted electronically through a confidential HIPAA compliant portal directly to The Meridian Group and will only be seen by your clinician. It should take about 10 minutes to complete. Both parents/guardians will need to complete their own form.

Your Name*

First NameMiddle NameLast NameSuffix

Name of Other Co-Parent/Co-Guardian*

Date of Appointment

MonthDayYear

Name of Your Clinician*

John Dwyer, PhD, Licensed Clinical PsychologistMelissa Findlay, LCSW, Licensed Clinical Social WorkerDavid Epstein, PsyD, Licensed Clinical PsychologistElizabeth Novak, LCSW, Licensed Clinical Social WorkerJill Sexton-Newton, LPC, Licensed Professional CounselorJulianne Luck, MSW, Supervisee in Social WorkLeah Harlan, MA, Resident in CounselingChelsi Simmons, LPC, Licensed Professional Counselor

Your Age

Date of Birth*

MonthDayYear

Your Gender

MaleFemaleOther

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Email*

example@example.com

Who Referred You to Our Office?

Occupation

Highest Educational Level

Name, Ages, & Gender of Your Children

Marital Status

Current Spouse / Partner Name

Presently Living With

Name(s) and Relationship

Current and Previous Mental Health Treatment Including Counseling, Testing, and Medication. When and by whom?

Date(s) of Current & Previous Marriages

Current Visitation Schedule

What is the current custody agreement and is it final? Is There a Current or Impending Court Hearing. If yes, describe.

Your Attorney

Currently Retained?

YesNo

Do You Have a Guardian Ad Litem? If Yes, Their Name

What outcome do you hope to reach in coparenting?

What do you feel are the biggest challenges/obstacles to your co-parenting relationship?

Please describe your children including adjustment to visitation, school issues, peers, etc. If they are in counseling, who are they seeing?

What effect do you believe the current state of your co-parenting relationship is having on your children?

Please prioritize the issues you would like to see addressed in co-parenting.

What would need to change to feel you have a adequate or good co-parenting realtionship?

Would you rather do in office visits or telemedicine visits for coparenting. We will discuss options on your first visit.

In OfficeTelemedicineNo PreferenceUnsure

Any other thoughts, concerns, or questions?

Policies:

I agree to make my portion of payment each session. Each session is $200 per hour and is not covered by insurance. Typically each parenting partner pays half ($100) for each session unless other arrangements are made. If a session is missed without notice, payment will still be due. Brief contact with attorneys will not result in a charge, but extensive time with attorneys or others involved will be charged $100 per hour, billed by the quarter hour, including letters or reports.

Court appearances or depositions are not typical for coparenting. However, if a court appearance is required, a minimum of $750 which includes the first 3 hours of time. There is an additional charge of $200 per hour when more than three hours is required. The fee of $750 is due fourteen (14) days in advance of the court date. Payment is due regardless of who initiates a court appearance. For contact with others involved in legal proceedings (e.g.: attorneys, CASA workers, guardians ad litem, social services, court appointed evaluators, judges) the cost is $200 per hour, billed by the quarter hour.

If you have any questions regarding coparenting or the information provided, please do not hesitate to ask you clinician. Your signature indicates you agreement to the terms of coparenting.

Signature*

Date of Signature*

MonthDayYear

Co-parenting Intake Questionnaire