Interview Intake Form

Please enter all required fields and those that apply
You may copy & paste answers into this form from a WORD document

Child's Full Name

Child's Birth Date

Court Case Number

Date of Separation

Your Full Name

Your Phone Number

Your Email

Your Address, City & Province

Lawyer's Full Name

Lawyer's Phone Number

Lawyer's Email

Lawyer's Address, City & Province

Does the child have a disability the interviewer should know about?
If so, please specify.

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

Child’s extracurricular activities (soccer, dance)

Name(s) of child’s close friends

Are there any circumstances in the child’s life that are particularly stressful for him/her at this time?
Please give as many details as possible.

What are the current living arrangements?
(location of child’s primary home, how much time is spent with the parent who does not live in their primary home)

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

Has the child been notified about this arrangement?
If so, what have they been told?

Who else lives in the primary home, including people and pets?

Who visits the primary home on a frequent basis?
(extended family, neighbors, friends, “significant others”)

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