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Family Specialist 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?_______________________________________________________________________________________________________________
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):
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:
As clients, you understand and agreed to:
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:
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
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?_______________________________________________________________________________________________________________
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:
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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.
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Signature Date
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Printed name, Client