Our Intake Process

Name[s] and birth date[s] of child[ren] involved in this case:

Name
Date of Birth

Name
Date of Birth

Your name, address, phone number[s]:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Biological Mother:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone

Biological Father:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone

Foster Parents/Guardian/Adoptive Parents/ Custodian:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone

What type of proceeding is this:

custody adoption abuse/neglect guardianship foster care paternity other

Court in which your case is pending:

Name of Court
Street Address
Address (cont.)
City
State
Zip/Postal Code

pretrial status conference trial appeal other

Date of next hearing :

-- mm/dd/yy

Case number:

Is the child being represented by an attorney or other advocate? If so please include his/her:

Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Name and phone number of Legal Representative:

Are you satisfied with the legal representation you have been receiving? If not please explain:

Has this case received any publicity? Please cite:

Are mental health professionals involved? If so please discuss his/her/their role and position concerning custody/placement of the child[ren]:

You MUST provide a detailed summary of the events of this case: