INTERVIEW INTAKE FORM FOR CHILD INTERVIEWS

Please note that, if more than one family member will be interviewed, you must complete a separate Interview Intake Form for each child.

Child's Name(*)

Invalid Input

Child's Date of Birth(*)

Invalid Input

Names of the Parties as they Appear on Court Documents (e.g., J. Jones &. T. Smith)(*)

Invalid Input

Court Case File Number

Invalid Input

Court Location (i.e., which city)

Invalid Input

Provincial Court or Supreme Court?

Provincial Supreme Invalid Input

Who is paying for this interview and report?

Invalid Input

Is there a court order specific to having your child interviewed?

Yes No Invalid Input

Has Ministry for Children and Family Development been involved with your family? If yes, please provide details.

Invalid Input

Have the police been called to your home with regard to a domestic dispute? If yes, please provide details.

Invalid Input

Date of Marital Separation

Invalid Input

Your Name(*)

Invalid Input

Your Telephone Number(*)

Invalid Input

Your Email(*)

Invalid Input

Your Mailing Address (please include postal code)(*)

Invalid Input

Lawyer's Name

Invalid Input

Lawyer's Telephone Number

Invalid Input

Lawyer's Email

Invalid Input

Lawyer's Mailing Address (please include postal code)

Invalid Input

Child's School, Grade, Teacher's Name(*)

Invalid Input

Child’s Extracurricular Activities(*)

Invalid Input

Does the child have a disability the interviewer should know about (e.g., medical condition or disability)? If so, please provide details(*)

Invalid Input

Are there any cultural considerations that need to be addressed for the child to be interviewed? If so, please specify

Invalid Input

What do I need to know about the child to help the child talk to me or help me talk to the child?

Invalid Input

Are there any circumstances in the child’s life that are particularly stressful for him/her at this time?

Invalid Input

What is the current parenting arrangement (i.e., What is the schedule for when the child spends time in each home? What happens during holiday periods? For how long has this schedule been in place?) (*)

Invalid Input

Who else lives in your home? Who visits your home on a frequent basis (e.g., extended family, neighbors, friends, “significant others”)? (*)

Invalid Input

Who else lives in the other parent’s home? Who visits the other parent’s home on a frequent basis?

Invalid Input

Since separation, have there been living arrangements other than that described above? If so, please specify

Invalid Input

What particular issues would you like the interviewer to explore with the child? (this is your opportunity to provide me details and concerns that you believe to be important).(*)

Invalid Input

You must also complete either a Consent Agreement to Hear the Children or a Consent of Agreement to Views of the Children, depending on which type of interview you are requesting. If more than one family member is to be interviewed, all of the children’s names can be included on one Consent Form.

Non-evaluative Views of the Child Interviews

Evaluative Views of the Child Interviews