Client Intake Questionnaire General Information Name: First Name Last Name Date of session: MM DD YYYY Referred by: Date of birth: MM DD YYYY Any confidentiality concerns (electronic stalking, etc.)? Current marital status? Length of relationship or marriage? Date of separation? MM DD YYYY Address: Address 1 Address 2 City State/Province Zip/Postal Code Country Phone: (###) ### #### Email Emergency contact (name, email and phone number): Names and Ages of Children Name: First Name Last Name Age: Gender: Information we should know: Name: First Name Last Name Age: Gender: Information we should know: Name First Name Last Name Age: Gender: Information we should know: Name First Name Last Name Age: Gender: Information we should know: Information on Current Situation What is your current custody arrangement (time division, legal and physical custody, etc.): Provide a summarized (nutshell) description of your divorce or child custody battle: Please describe your ex-partner – what is their profession, background, addictions, strengths, weaknesses or anything else that we should know: What topics are you most interested in exploring? Examples are: setting boundaries, communication, strategy, understanding the system, emotional support, documentation, preparation for evaluations, etc. Please list three items that you want to focus on during our time together: Your Team Attorney: are you currently working with an attorney and if so, who is your attorney? Do you feel that your attorney understands high-conflict individuals? Please explain: Divorce professionals (past and present): are you currently involved with custody evaluators, minor’s counsel (GAL), child welfare services or other legal professionals? Details are helpful and appreciated. Please provide names of the judge and any professionals involved in your case: Therapy: are you (or your children) currently under the care of a therapist? If so, please describe your relationship with him/her. Do you feel like he/she understands trauma and high-conflict divorce? You What is your knowledge of your local court system (scale of 1 – 10)? If you were placed on a scale (1 being “very low”) that measured your “strategy mindset” at this present moment, what score would you give yourself? If you were to meet with a complete stranger for one-hour, how would they describe you? What are your greatest strengths and your biggest weaknesses? The Lemonade Club (TLC) is my private, online forum. If you are interested in receiving information on TLC, please provide the email address that we should use to contact you: Thank you!