Wendy Rawlings
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Child Specialist Intake Forms

  • Please  print this form out, complete and bring with you to your first appointment

    Child Information Questionnaire

    (To be completed by each parent for each child)


    Child’s Name: ________________________________________________  Sex: Male / Female

    Date of Birth: _______________________ Age: _____________ Grade in School: ________

    Person completing this form: (Name) _______________________ Mother _____ Father _____

    Currently this child lives with: (Check one)

    _____ My spouse and I in the same household (pre-separation)

    _____ With me _____ days and ___ overnights per (check one) ___ week ___ month

    _____ Other parent ___ days and ___ overnights per (check one) ___ week ___ month

    _____ Other arrangement (explain)

              

    School, Friendships, Social Life

    School or pre-school your child attends: _________________________________________

    Name of your child’s teacher: _________________________________________________

    How many different schools has your child attended? __________

    Child’s academic performance in the past 12 months has been:

    _____ Outstanding   _____ Above Average   ______ Average   ______ Below Average

    Has there been a change in your child’s academic performance over the past 12 months?  (circle one) Yes / No 

    How does your child feel about school:

    _____ Appears to love school     _____ Likes it enough     _____ Doesn’t like school

    Does your child participate in extra-curricular activities? Describe: ______________________________________________________

    Approximately how many good friends does your child have?

    _____ None   _____ One or two   ______ 2 - 4   ______ 5 – 7   _____ More than 7

    Does your child have a best friend?     _____ yes     _____ no

    Please indicate, with regard to your child, what one personal activity, event, skill, or accomplishment are you proudest of? 


    ____________________________________________________________________________________________________________


    Child’s Temperament and Coping Skills

    Over the past year, has your child experienced the loss of a loved one (i.e. relative, caregiver, friend, pet, etc.), through death, extended separation, moving away or other circumstances?   If yes, please explain:   ___________________________________________________

    How does your child deal with changes (i.e. new schools, babysitters, friends, new schedules, etc.)?  _______________________________


    _____________________________________________________________________________________________________________

    What have you found helps her/him cope with these changes? ____________________________________________________________

    How does your child deal with separating from you (i.e. leaving for school, sleepovers, camps, etc.)?  _______________________________

    What helps your child with separations? _____________________________________________________________________________

    Circle any problems your child has experienced (and add specific information, if desired):

    1. Temper tantrums

    2. Rejection or made fun of by peers

    3. Bullied or manipulated by peers

    4. Shyness

    5. Nightmares

    6. Bedwetting / soiling at night

    7. Wetting / soiling during the day

    8. Acts your for his/her age

    9. Difficulty making friends

    10. Difficulty keeping friends

    11. Aggressiveness, picking fights

    12. Discipline problems at school

    13. Cruel or malicious to other children or animals

    14. Delinquent acts such as breaking windows, shoplifting, etc.

    15. Argues a lot

    16. Difficulty concentrating

    17. Restless, difficulty sitting still, hyperactive

    18. Complains of loneliness

    19. Appears sad, unhappy, or depressed

    20. Changes in eating habits

    21. Sleep problems

    22. Harms self deliberately

    23. Suicidal thoughts

    24. Fearful, shy

    25. Refuses to go to school

    26. Clingy with parents, caregivers

    27. Destroys property of self, family, others

    28. Accident-prone

    29. Physical complaints with unknown medical causes:

    _____ Headaches     _____ Nausea, vomiting     _____ Aches/pains  _____ Rashes, skin problems     _____Stomach aches

    1. Use of non-prescription drugs, abuse of prescription drugs, or abuse of alcohol

    2. Noticeable difficulty with changes in routines, schedules

    Child’s Perceptions, Reactions to the Separation/Divorce

    What are your child’s reactions to the circumstances surrounding your separation/divorce? 
    __________________________________________________________________________________________________________

    What have you told your child about the situation?  __________________________________________________________________________________________________________

    Does your child ask questions or talk about the separation/divorce? If so, what does your child seem most concerned about?

    ___________________________________________________________________________________________________________

    In what ways might your child benefit from the separation/divorce?  ___________________________________________________________________________________________________________


    Siblings, Relatives, and Family Friends

    Does your child have sisters or brothers? _____ yes     _____ no

    Are there concerns about this child’s relationships with his/her siblings?  If so, what  are they? __________________________________________________________________________________________________________


    Who are other relatives and family friends who are especially important to your child?  __________________________________________________________________________________________________________


    What should we know about his/her relationships with siblings, extended family members, or special family friends?  ___________________________________________________________________________________________________________


    Parent-Child Relationship

    What are your strengths as a parent?  ___________________________________________________________________________________________________________

    What are your weaknesses as a parent?  ___________________________________________________________________________________________________________






    WENDY RAWLINGS  M.S.  LMHC

    33600 6th Ave. South, Suite 212, Federal Way, WA 98003


    CONTRACT FOR FAMILY SPECIALIST

    This contract outlines our agreement regarding my providing family specialist services to support your collaborative law dissolution.  Because you decided to use a collaborative process for your dissolution, I agreed to provide you specific assistance to support that effort.  Before you sign this contract, please make sure you agree to all of its stipulations.  You may hold off signing until you review this document with an attorney.

    You (the “the clients”) are retaining me, Wendy Rawlings (the “the specialist”), to provide services with your collaborative law case, in which you both share a commitment to resolve disputes without resorting to litigation.  The process entails a series of conversations and meetings with the ultimate goal of settling all issues, and where all agree to adhere to principles such as honesty and mutual respect.  

    Professional Credentials:

    EDUCATION

    M.S.  Counseling Psychology, Eastern Washington University, Cheney, WA, June 1988

    B.S.   Child Development and Family Relationships, Brigham Young University, Provo, UT, April, 1975

    Private Practice 1990-present

    Guardian ad Litem 1989-1998

    Guest Lecturer, University of Washington 1993-2003

    Collaborative Law Training 2007

    Mediation Training 2007

    Advanced Collaborative Law Training 2007, 2008

    Member, International Academy of Collaborative Professionals; South King County Collaborative Law; Collaborative Law Professionals of Pierce County; Collaborative Professionals of South King County; and Board Member of Collaborative Professionals of Washington

    In consideration of the mutual promises contained in this document, you and I agreed that this contract is made subject to the following terms and conditions:

    My services are to help you achieve a marital dissolution, which will minimize the negative impacts upon social, emotional and financial aspects of your life and the lives of your children.  

    I have agreed to work as a member of a collaborative team to facilitate communications and help resolve conflicts throughout the dissolution process.  Specifically, I have agreed to help you:

    1. Identify and prioritize your concerns;

    2. Clarify your goals and objectives;

    3. Bring focus to the best interests of the children;

    4. Utilize effective and respectful negotiation processes;

    5. Ensure constructive communication skills are applied; and

    6. Sustain a collaborative environment.


    As clients, you understand and agreed to:

    1. Be respectful and courteous to all parties and professionals involved;

    2. Candidly communicate your ideas, thinking and concerns;

    3. Demonstrate you are open to new ideas and approaches to problem solving, which are beyond your own experience;

    4. Be forthcoming with information needed by the parties and professionals;

    5. Allow others to speak without interrupting them;

    6. Encourage and support efforts to collaborate with others;

    7. Focus on the best interests of the children; and

    8. Work as a team member to help reach a consensus on the content of the dissolution documents and forms.

    Further, you agreed to:

    1. Not engage in any court action other than as specifically agreed to and allowed under your signed Participation Agreement.

    2. Hire, support and provide information to professionals as may be required; for example, family law attorneys, financial specialists, specialists in psychology of children, and others needed to reach resolution to questions and concerns.

    I am not trained in the law and I cannot interpret laws.  I cannot assess what would happen if you were to withdraw from collaborative processes and then present your concerns to a court.

    You acknowledge and understand that the normal privacy and confidentiality practices applied by mental health counselors and similar professionals and their clients do not apply here.  I will share with other individuals involved in the collaborative processes your ideas, analyses, proposals, and other statements you make to me.  You do not expect me to hold confidential things you say.  However, I agreed to hold confidential what I hear and see throughout the collaborative processes and prevent release by me, except under court order, to individuals not involved in the collaborative processes.

    You acknowledge that I will breach any and all confidentiality agreements between us, perceived or otherwise, if I come to believe:

    1. There is a threat of physical harm to an identifiable person;

    2. A person poses a danger to him/herself and/or others; or

    3. I have a suspicious of or actual knowledge of child abuse or neglect, abuse of a dependent or elder adult (65 or older)



    No Guarantees

    Success in building a collaborative environment that leads to lasting and meaningful dissolution agreements is dependent on many factors.  Some of those factors are:  Issues that are identified, the motivation of the parties to succeed, the efforts made by the parties to fulfill their responsibilities, and the parties’ commitment to collaborative processes. Despite these uncertainties, I will work with you and do my best to help you realize your goals for this process.

    I cannot provide guarantees.  

    Fee

    You agreed to pay my usual fee of $150 per hour. Time will be billed in minimum increments of 10 minutes. Payment is due at the time of service.  Payment for work done outside of your presence or by telephone or email will be due within 10 days of service. My services will stop anytime your account is not kept current.  If you object to any fee or expense, you will notify me immediately by telephone.  There will be a $25 fee for any returned check.

    This fee will apply to all my efforts supporting you including, but not limited to, time: In team meetings, in one-on-one meetings with yourself or with supporting professionals, traveling to and from meetings, writing documents, completing forms, writing and responding to e-mail, and responding to telephone calls.

    There will be no charge for a telephone conversation of just a few minutes.  If you contact me relative to an issue that you do not believe that I should charge for my time discussing the matter with you, whether on the telephone or in person or by e-mail, let me know early-on in our conversation.

    I may bill for and you agreed to pay for one hour of my time for any missed appointment that you did not cancel at least 24 hours in advance.

    Client Files

    I will maintain my files related to the services provided in this effort for four years after the final papers are entered in the case or the last date that I participate in your collaborative processes, whichever is earlier.  

    Limitations of Subpoena Power and Errors and Omissions Liability

    You will not subpoena me or any person employed by or affiliated with me to testify or provide information in any action or proceeding arising out of or connected in any way with this collaborative process or any dissolution-related court action.  You will not hold me liable for any error or omission in connection with this collaborative process or associated documents.


    Communication Tools

    When we are not face-to-face, I intend to communicate with you using voicemail, e-mail, postal service mail, fax, and telephone.  If you prefer a different arrangement, please let me know.

    Ethical Standards

    To the best of my ability I will adhere to the ethical standards developed by the International Association of Collaborative Practitioners.

    Contract Termination

    This contract ends upon the signing of dissolution papers or when the collaborative process is either complete or terminates.  If I provide you with two days prior notice, I may withdraw from this process for any reason.  In such an instance, I would notify you in writing and provide you with potential options to replace me.  If you withdraw from the collaborative effort and/or begin or continue with any court action for any reason, my services will end.  You may terminate my services at any time for any reason.  Regardless of the above stipulations, this contract will continue to be valid until all fees are paid.

    Entire Agreement and Interpretation

    This contract represents our entire agreement and there are no other provisions, oral or written, that exist between us that modify or supplement this contract with the exception of the Collaborative Participation Agreement if signed.  The terms of this contract may only be modified by a dated, written agreement signed by the same parties that signed this contract. The laws of the State of Washington shall govern the provisions of this instrument.  Should any clause of this contract prove to be invalid or void, it shall not affect the whole contract, but only that portion found to be invalid or void.  

    Signed:

    ________________________________________                     _________________________

    Wendy Rawlings M.S.  LMHC                                                                                        Date



    Clients’ statement accepting contract:  I have read the above contract, consisting of  pages, including this page, and I agreed to it in full.  I have been given an opportunity to review this document with an attorney before signing.


    ________________________________________                     _________________________

    Signature                                                                                                                                                         Date


    ________________________________________

    Printed name, Client























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