In-Home Custody Evaluation Intake

In-Home Custody Evaluation Intake
Please complete this intake form to assist with the in-home custody evaluation process. All information will remain confidential and is necessary for a thorough assessment.
Parent/Guardian Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Relationship to Child(ren)
Child(ren) Information
List all other household members (name, age, relationship)
Reason for Evaluation
Other
Current Custody Arrangement
Home Environment & Parental Cooperation Assessment
Rows Excellent Good Fair Poor
Cleanliness of home
Child's sleeping arrangement
Safety of environment
Parental cooperation
Emotional atmosphere
Are there any current safety concerns (e.g., domestic violence, substance abuse, neglect)?
Other
Please provide any additional information or concerns relevant to the evaluation.
I confirm that the information provided is accurate to the best of my knowledge.
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Rows	Excellent	Good	Fair	Poor
Cleanliness of home
Child's sleeping arrangement
Safety of environment
Parental cooperation
Emotional atmosphere