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Cause Number*
Referring Court*
Ordered by Court*
What party is this form submitted for?*
Name*
Relationship to Children*
Please enter in Relationship to children*
Primary Phone Number*
Cell Phone Number
Email Address*
Confirm Email Address*
Date of Birth*
Occupation
Income*
Does PetitionerRespondentThird Party have an attorney*
Email Address
Please confirm email address
Phone*
Cell Phone*
Other Party Name:
Other Party Phone:
Is there an Amicus Attorney involved?
Name
Phone
Cell Phone
Child One Name*
Child One Date of Birth*
Child Two Name
Child Two Date of Birth
Child Three Name
Child Three Date of Birth
Child Four Name
Child Four Date of Birth
Child Five Name
Child Five Date of Birth
Is the Office of Attorney General Involved in this Case*
Unit Number(s)
Type of Case?*
Date of Marriage/Relationship
Date of Separation
Is there a Temporary Order?*
Date of Temporary Order?
Children are residing with*
Active CPS Case?*
Active protective order?*
If active protective order, against whom?
Issues to be mediated*
Issues to be mediated Other
Has a party been struck, kicked, bitten, choked, burned or otherwise hurt by the other party?*
If yes, please explain
Has a party been threatened or hurt with a knife, gun or other object by the other party?*
Has a party been emotionally abused or verbally threatened by the other party?*
Have the children been abused, beaten, neglected or otherwise deliberately injured?*
Have you any reason to believe that a party uses illegal drugs or abuses alcohol or prescription drugs?*
If yes, please explain*
Have you any reason to believe that the other party is suicidal or not able to make rational decisions regarding the children due to mental or emotional illness?*
Please enter the name of person that filled in this form*
What is the relationship of the person completing the form to the case?*
