INTERVIEW INTAKE FORM – THE VIEWS OF THE CHILD

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(*)

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Child's Date of Birth(*)

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

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Court Case File Number

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Provincial Court or Supreme Court?

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Court Location (i.e., which city)

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Date of Marital Separation

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Your Name(*)

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Your Telephone Number(*)

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

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Your Email(*)

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Lawyer's Name

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Lawyer's Mailing Address (please include postal code)

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Lawyer's Telephone Number

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Lawyer's Email

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

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Child’s Extracurricular Activities(*)

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

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

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

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

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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?) (*)

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

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

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

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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).(*)

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