1) How would you describe the level of cooperation between you and your spouse? (Check one)
High
Medium
Low

2) How would you describe the level of hostility between you and your spouse? (Check one)
High
Medium
Low

3) What are the arrangements for your children to see the other parent?
Where?
How frequently?
For how long?
Handover routine & site?
Predictability/Reliability?

4) Are the schedule arrangements fair and mutually agreeable?
Yes
No

5) What are the arrangements for your children to communicate with the other parent? (Check those that apply)
Phone?
Fax?
Email?

6) What is the most difficult question your children have asked you?

Why did you have difficulty answering?

7) What concerns have your children brought to you?

How have you tried to reassure the children? Yes/No

8) Do your children know what it says in the divorce agreement re:
Child support?
Visiting schedule?
Holiday arrangements?
College tuition responsibilities?

Have they read the divorce agreement? Yes/No

9) Have you seen the following behavior changes at home? Yes/No
Discipline problems
Increased compliance
Sleep changes
Eating changes
Anger
Withdrawal
Regression

10) Has school notified you of any of the following behavior changes? Yes/No
Academic
Peer
Discipline
Aggression
Withdrawal
Increased compliance

11) What steps would you like to see taken to improve life for the children?

12) What would you like to see stopped to improve life for the children?

13) What changes do you anticipate in the next six months? (Check those that apply)
Moving?
New job?
New relationships?

14) Which of the following are part of your/your child(ren)'s support system? (Check those that apply)

Grandparents/family members?
Friends/neighbors?
Teachers?
Coaches?
Peers?
Mental health professional?