QUESTIONNAIRE

Each party is to fill out questionnaire before visitation starts

Today‚Äôs Date: _________________ 

INFORMATION ON YOURSELF:  

Custodial Parent/Non-Custodial Parent (CP/NCP)

Please circle whether you are CP or NCP.

Name: ______________________________________________

Home address:_______________________________

City:________________ State_____________

Zip Code________

County:______________ DOB:____________________

Cell Phone: ______________

Other number:_______________

E-Mail address: _______________

Fax number:___________

Driver's License Number: ___________

Issuing state: _______

Year and make of car you are using:_____________________

License plate number: ______________________

Emergency contacts:

Name:__________________________ Phone:____________

Name: __________________________ Phone:___________

If represented by counsel in this matter: Please complete the following:

Attorney name:_______________________________

Street address:________________________________

City:_____________ State:___________

Zip code: ________

Phone number:________________

Fax number:___________

Email address: __________________

Amicus Attorney:

Attorney name: ____________________________________

Street address: ______________________________

City:_____________ State:___________

Zip code: ________

Phone number:________________

Fax number:___________

Email address: __________________

Case information:

Court number: __________ Cause no.____________

Any hearing dates:___________________________

Please attach any current orders regarding supervised visitation.

Children's information

Name:_____________________________ DOB:________

Name:_____________________________ DOB:________

Name:_____________________________ DOB:________

After filling out questionnaire and executing the rules and regulations, scan and email them to me at: [email protected]

Also, provide the program with a copy of your driver's license front and back.