Hear The Child Reports “Family is where life begins and love never ends.” — Unknown “Finding a new way to be a family takes time, love, and support, but it’s worth the effort.” Please complete the following information to compete the Hear The Child Intake form. Name * First Name Last Name Pronouns (how would you like to be addressed) Email * Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How do you prefer to be addressed/ what are your preferred pronouns? She/Her He/Him They/Them Own Name Other How did you hear about me and my services? * Psychology Today Mediator/ Legal Services BCACC Website CCPA Website Family/Friend Other How do you wish to be contacted? * Phone Email No Preference Do you have legal representation? * Yes No Name, Phone and email for your Legal Counsel What is the name of the other Parent/Guardian? * First Name Last Name Does the opposing party have legal representation? * Option 1 Option 2 Has Hear the Child Report been court-ordered or otherwise formally agreed upon? * Yes No How many children will be interviewed? * One Two Three Four Five Names and Date of Birth of each child * Please provide the Full Legal Name of each child and their Date of Birth When is the final Hear the Child Reporting required to be submitted? Please note the time requirements in advance of a trial or court appearance for which the reporting will need to be provided. * * MM DD YYYY If Court, what level? * Court Case Name and Number Is Report to be filed? Yes No Have the court(s) or the parties in the file determined cost-sharing? * * Yes No Do both parents/legal guardians intend to participate in the parent intake component of the Hear the Child Report preparation? * Yes No Do you have all applicable documentation readily available should your file be accepted (i.e. court/consent orders for the preparation of a Hear the Child Report, court/consent orders for parenting access/arrangements, separation agreements, letters of instruction from legal counsel, etc...) to disclose to the report writer? * Yes No Is financing secured for this service in order to provide a retainer? * Yes No Have you reviewed the most recent Fee Schedule? * Yes No What are the transportation plans: Date of Seperation MM DD YYYY Nature of any Court Application or Dispute between Guardians: Description of current Parenting Time Schedule: Purpose of the Report: Issues (generally) to be canvased with the child(ren): Name of Child One * First Name Last Name To be interviewed? Yes Name of Child Two First Name Last Name To be interviewed? Yes Name of Child Three First Name Last Name To be interviewed Yes Name of Child Four First Name Last Name To be interviewed? Yes * I confirm that, to the best of my knowledge, the information I have provided above is true and accurate. As such, I accept full responsibility for any delays, denial of service, or cancellation of service that may occur should this information be incorrect, misleading, or untrue. I agree that a copy of this intake form will be sent by e-mail to myself and my legal counsel (if applicable), and authorize such disclosure. I confirm that I have read and agree to the Technology Terms of Use & Consent, the Privacy Policy, and the website Terms of Use, and consent to Heather Thrasher or an authorized representative of Grit & Growth Therapeutic Solutions Ltd., contacting me for the purposes of providing service(s) to myself or my family. I agree * I agree Thank you! I confirm I have read the Fee Schedule
