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):- Temper tantrums
- Rejection or made fun of by peers
- Bullied or manipulated by peers
- Shyness
- Nightmares
- Bedwetting / soiling at night
- Wetting / soiling during the day
- Acts your for his/her age
- Difficulty making friends
- Difficulty keeping friends
- Aggressiveness, picking fights
- Discipline problems at school
- Cruel or malicious to other children or animals
- Delinquent acts such as breaking windows, shoplifting, etc.
- Argues a lot
- Difficulty concentrating
- Restless, difficulty sitting still, hyperactive
- Complains of loneliness
- Appears sad, unhappy, or depressed
- Changes in eating habits
- Sleep problems
- Harms self deliberately
- Suicidal thoughts
- Fearful, shy
- Refuses to go to school
- Clingy with parents, caregivers
- Destroys property of self, family, others
- Accident-prone
- Physical complaints with unknown medical causes:
- Use of non-prescription drugs, abuse of prescription drugs, or abuse of alcohol
- Noticeable difficulty with changes in routines, schedules
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:- Identify and prioritize your concerns;
- Clarify your goals and objectives;
- Bring focus to the best interests of the children;
- Utilize effective and respectful negotiation processes;
- Ensure constructive communication skills are applied; and
- Sustain a collaborative environment.
As clients, you understand and agreed to:- Be respectful and courteous to all parties and professionals involved;
- Candidly communicate your ideas, thinking and concerns;
- Demonstrate you are open to new ideas and approaches to problem solving, which are beyond your own experience;
- Be forthcoming with information needed by the parties and professionals;
- Allow others to speak without interrupting them;
- Encourage and support efforts to collaborate with others;
- Focus on the best interests of the children; and
- Work as a team member to help reach a consensus on the content of the dissolution documents and forms.
- Not engage in any court action other than as specifically agreed to and allowed under your signed Participation Agreement.
- 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.
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:- There is a threat of physical harm to an identifiable person;
- A person poses a danger to him/herself and/or others; or
- 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 - Temper tantrums
