Intake Form for High Conflict Parent Partnership Course

First and Last Name

Email Address

Cause Number and Date of Court Order

Address

Best Telephone Number to Reach You

Please list the Children and their ages from the relationship/marriage with your co-parent.

Do you have other Children? Please list their ages and who they live with.

Are there any past or current protective/restraining orders of protection issued against you or your co-parent?(required)

Yes

If you answered Yes to the question above, please explain.

Co-Parent's Name

Co-Parent's email address (if known)

Co-Parent's telephone number

What is your regular or weekly parenting time schedule?

What is your Holiday Parenting Time Schedule?

What is your extended (summer) parenting time schedule?

Who is your attorney of Record?

How do you intend to pay for the class? Cash, Money Order or Credit Card? **There is a 3% processing fee for Credit Card Transactions**

Today's Date

Do you have any questions?