Wendy Rawlings
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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):

  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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