Ad Litem’s Basic Questionnaire for Parentsthe information we need to help you

Full Name
First Middle Last
Birth Date
MM slash DD slash YYYY
Permanent Address
Street Address Address Line 2 City State ZIP Code
Current Address (if different than permanent address)
Street Address Address Line 2 City State ZIP Code
Employer
Occupation
Normal work hours and work days:
How long have you worked for your current employer?
If less than three years with your current employer, where did you work prior?
Please list the full names and ages of all persons living with you on a full time basis:
If any person living with you full time is not related to you by blood or marriage, please provide details of the relationship:
Do you have health insurance for yourself?
- Yes
- No
Are your children covered under your policy?
- Yes
- No
Do you have reliable transportation?
- Yes
- No
Do you have age appropriate car seats/seat belts for all children you transport?
- Yes
- No
By what means do you get to and from work and transport your children to places they need to go?
State your gross income for the previous calendar year:
If you are paying child support for any children not involved in this case, how much per week/pay period/month?
Please identify any medical conditions for which you have a current diagnosis (examples – high blood pressure, diabetes, hypothyroid, asthma, i.b.s., etc.)
List all medication you are currently prescribed for medical conditions identified in response to question 17 and the regularity the medicine is prescribed to be taken (i.e. twice a day, daily, weekly, as needed, etc.):
Please identify any mental conditions for which you have a current diagnosis (examples - post-traumatic stress disorder, depression, Adult ADHD, etc.):
List all medication you are currently prescribed for mental conditions identified in response to question 19 and the regularity the medicine is prescribed to be taken (i.e. twice a day, daily, weekly, as needed, etc.):
Do you observe a particular religious or spiritual practice with your children?
- Yes
- No
Please specify the particular religious or spiritual practice and the frequency of attendance or observation:
How do you discipline your children?
Please list the relatives that live within 100 miles of your permanent address:

Name, Relationship, Address, & Telephone Number
Please list the full name and birth date of the children you have with the other party/parent:
Please identify the name and address of the school each child attends:
For each child, please identify any medical, dental, or optometric problems or issues the child may have (i.e. allergies, asthma, etc.):
For each child, please identify any mental health diagnosis the child currently has or has had in the past 5 years:
Please identify by name, address, and telephone number the mental health professional making the diagnosis:
For each child, please identify all medications the child takes for mental health purposes and the regularity of the medication (i.e. morning and evening, daily, weekly, monthly, seasonally, etc.):
Do any of the children have a learning disability or challenge?
- Yes
- No
Does the child have an Individual Education Plan (IEP) with their school?
- Yes
- No
Please state the nature of the learning disability or challenge:
Do any of the children have disciplinary issues at school?
- Yes
- No
Please state the nature of the disciplinary problems and the actions being taken by the school:
If any of the children you have which are the subject of the current case are younger than 5 (school age), please state how they are cared for while you are at work:
If you are using a day care for your younger than school aged children, please state the name and telephone number of the facility and the name of a contact person:
If applicable, describe how, where, and when the child/children are exchanged with the other parent:
If your child/children attend a school which has electronic parental access such as EdLine©, does each parent have passcode access?
- Yes
- No
List all extra-curricular activities in which your child/children are enrolled at the present time:
For each activity, please state the schedule for each activity:
List all extra-curricular activities in which you anticipate your child/children participating in the next year?
For each anticipated extra-curricular activity please state if there is an agreement between parents and which parent signs up the children and pays fees:
Do they participate in any school activity such as sports or band which require after or before school attendance?
- Yes
- No
Please describe how attendance is coordinated with the other parent:
Does your child have a cell phone?
- Yes
- No
With which parents cell phone plan is the phone currently registered?
Does your child have a Facebook® account?
- Yes
- No
Which parent has control over the child's account?
Does your child have any other social media accounts?
- Yes
- No
Please list the other accounts and which parent reserves control over the account:

Name*
First Last
Phone*
Preferred Day*
MM slash DD slash YYYY
Preferred Time of Day*

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Ad Litem’s Basic Questionnaire for Parentsthe information we need to help you

Need more information? Contact the Carter Law Firm.

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