Wendy Rawlings
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Divorce Coach Intake Forms


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

  • Marital History Questionnaire

    Name________________________________ Date of Birth______________

    Address_______________________________________________________

    City___________________________ State__________ Zip_____________

    Phone (Home) _________________   (Work)_________________________

    I prefer to be called at:  Home_____  Work______  Either______

    Email address__________________________________________________

    Wife’s attorney_________________   Husband’s attorney_______________


    Children

    Name  and date of birth  Child currently lives with:        Mother   Father   Both

    ________________             __________________                  _____     _____    ____

    ________________              __________________                  _____     _____  ____

    ________________            __________________                   _____      _____  ____

    ________________            __________________                   _____      _____    ____

    ________________         __________________                    _____       _____    ____


    Current Marital Circumstances

    Years married________________ Date of Marriage_______________

    Reason you married_____________________________________________

    Currently separated?  Yes___ No___ Date of separation_____________

    Filed for divorce?       Yes___ No___ Date of filing__________________

    Who filed?_____________________ Attorneys engaged  Yes___  No___

    Check one:

    Did you expect this separation? Did you want this separation/divorce?

    Yes, for a long time ______ Not at all     _____

    Yes, but only recently   ______ Have mixed feelings _____

    Unexpected ______ Want it very much _____

    No, but I’m resigned to it _____  Feel it is for the best _____


    Check one:

    Did your spouse expect this separation? Did your spouse want this separation/divorce?

    Yes, for a long time ______ Not at all     _____

    Yes, but only recently   ______ Has mixed feelings _____

    Unexpected ______ Wants it very much _____

    No, but is resigned to it _____  Feels it is for the best _____


    If previously married, list date(s) of previous marriages and divorces:

    _____________________________________________________________

    _____________________________________________________________


    Factors contributing to the decision to separate/divorce--Check all that apply

    Recently had difficulty communicating _______

    Always had difficulty communicating _______

    Different interests _______

    Differences in education levels _______

    Differences in ethnic or racial background _______

    Differences in expectations about marriage _______

    Differences in expectations about family life _______

    Changes in lifestyle, values _______

    Lacked love for one another _______

    Verbal abuse _______

    In love with another person _______

    Bored _______

    Sexual difficulties _______

    Financial problems _______

    Unfaithful, infidelity _______

    Abuse or neglect of children _______

    Job or school commitment _______

    Suspicious, jealous  _______

    Neglect of home _______

    Troubles with in-laws _______

    Drinking _______

    Drug use _______

    Physical abuse _______

    Depression _______

    Sexual abuse _______

    Other (explain) ___________________________________________________________________

    Major life events/changes occurring within the last 12 months-- Check all that apply:

    Started school or training program _______

    Graduated from school or training program _______

    Entered job market _______

    Changed job _______

    Lost job _______

    Changed residence _______

    Financial troubles _______

    Increase in financial responsibilities _______

    Legal problems _______

    Arrested and/or jailed _______

    Separation or divorce of friend or relative _______

    Health problems (self, spouse, children) _______

    Drinking or drug problems _______

    Began treatment for drinking or drug problems _______

    Began psychotherapy _______

    Major life events/changes occurring over last 12 months (cont.)

    Began new medication _______

    Significant weight gain or loss _______

    Nanny, au pair or aging parent joined the household _______

    Nanny, au pair or aging parent left the household _______

    Death of a household pet _______

    Pregnancy _______

    Miscarriage _______

    Abortion _______

    Fertility problems _______

    Changes in childcare _______

    Children having trouble in school _______

    Onset of menopause _______

    Mid-life crisis _______

    Victim of a crime _______

    Auto accident _______

    Undertaken major new expenses _______

    Natural disaster _______

    Major surgery _______

    Other (explain) _______

    _____________________________________________________________

    Personal concerns and priorities at time of separation or divorce

    What would the best outcome of the divorce look like to you? ____________

    _____________________________________________________________

    What is your greatest fear about your divorce? _______________________

    _____________________________________________________________

    During and after our divorce, I am concerned that our children will________

    _____________________________________________________________

    _____________________________________________________________

    What are you hoping for your life after the divorce? ___________________

    _____________________________________________________________

    What is your greatest fear after the divorce?__________________________

    _____________________________________________________________

    What are you hoping your relationship will look like after the divorce?_____

    _____________________________________________________________

    What do you hope your relationship with your now spouse will look like after the divorce as you develop a ‘co-parenting’ alliance:_______________________________________________________________________________

    What do you consider to be the main unresolved issues?

    1.__________________________________________________________

    2.__________________________________________________________

    2.__________________________________________________________

    4.__________________________________________________________

    5.__________________________________________________________


    Conflict Issues

    Please rate the level of trust you currently feel in your spouse as you start this process:

    1 is little trust—5 is very trusting

    1      2      3      4      5

    Please rate the level of cooperation and communication you see between you and your spouse now:

    1 is very closed and hostile—5 is very open and cooperative

    1      2      3      4      5

    Briefly describe how conflict looks like in your household (example—open hostility, we never fight, our conflict is often hidden)________________________________________________________________________________

    ______________________________________________________________________________________

    Please rate the worst level of conflict between you and your spouse during your marriage:

    1 is almost constant conflict—5 is very little conflict

    1      2      3      4      5

    What time period was the worst level of conflict during your marriage?_____________________________________________________

    What is the current level of conflict between you and  your spouse?

    1 is almost constant conflict—5 is very little conflict

    1      2      3      4    5

    In your marriage, have you and your spouse ever had conflict episodes that you might characterize as emotionally or physically violent?
     [ ] Yes  [ ] No

    If you answered yes, please explain________________________________

    _____________________________________________________________

    _____________________________________________________________

    Support System

    Current sources of emotional support--check all that apply:

    Friends _______  Family _______  Neighbors _______  Co-workers _______  Religion or spiritual practice _______

    Therapist/counselor _______  Lawyer _______  Clubs/organizations _______

    Other _______________________________________________________


    Your Occupation

    Name of employer______________________________________________

    Occupation_______________________ For how long?_________________

    How satisfied are you with current occupation?

    Very satisfied _______ Moderately satisfied _______

    Moderately unhappy _______ Extremely unhappy _______


    Personal History

    Have you ever had any physical or mental illnesses, significant health problems or serious accidents that affect you for an extended period of time?  If so, please   list:______________________________________________________________________________

    Are there any current health issues that might impact your ability to participate fully in this process or may delay this process? 
  • [ ] yes  [ ] no

    If yes, please explain_________________________________________________________________________________________

    Your health in early childhood was generally:

    Good_______ Fair_______ Poor_______

    How long ago was your last physical?_______________________________

    List all prescription and over-the-counter drugs you are taking (including aspirin, vitamins, sleeping pills, etc.)_____________________________________________________________________________________________

    Have you  ever been, or are you currently being treated for any drug or alcohol issues? [ ] yes  [ ] no

    Are there any current issues with drugs or alcohol that might impact your ability to participate fully in this process? [ ] yes  [ ] no

    Do you believe there are any current issues with drugs or alcohol that might impact your spouse’s ability to participate fully in this process? 
    [ ] yes  [ ] no

    Are you currently in couples, family, or individual counseling?____________

    If yes, with whom?______________________________________________

    Have you previously been in couples, family, or individual counseling?_____

    If yes, what type of counseling was it?______________________________

    Name of counselor_______________________ How long_______________

    Would you release your counselor to talk with me so I can educate him/her about the collaborative process?  (This does not release your counselor to talk with me about your therapy.)  [ ] yes   [ ] no


    Income

    What is your approximate gross monthly income?_____________________

    Describe any changes in your income since your separation_____________

    ____________________________________________________________


    Decision Making

    Major financial decisions in our family were primarily made by:

    Wife Husband Both

    Finances (paying bills, managing money, etc.) were primarily managed by:

    Wife Husband Both

    Decisions regarding household matters (household tasks, maintenance, etc.) were primarily managed by:  (circle one)

    Wife         Husband         Both

    Social aspects of our family (social events, decisions about vacations, etc.) were primarily managed by:  (circle one)

    Wife         Husband         Both

    As parents, decisions regarding our children (school events, extra-curricular events, doctor choices, general discipline, behavior issues) were primarily managed by:  (circle one)

    Wife         Husband         Both

    My spouse would agree with my assessment of the above questions:

    [ ] yes  [ ] no


    Process

    How did you hear about Collaborative Practice?______________________

    What do you hope to accomplish by choosing Collaborative Practice?  _______________________________________________________

    In addition to the information you have given above, what else do you feel is important for me to know about you, your family, and your current situation?___________________________________________________________________________________________________________








    CONTRACT FOR DIVORCE COACH
    This contract outlines our agreement regarding my providing Divorce Coach 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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