Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have legal representation? *

Yes

No

What is the name of the opposing party? *

First Name

Last Name

Does the opposing party have legal representation? *

Option 1

Option 2

Has Hear the Child Reporting been court-ordered or otherwise formally agreed upon? *

Yes

No

Have all parents/legal guardians provided their consent for Hear the Child Reporting to take place? *

Yes

No

How many children will be interviewed? *

One

Two

Three

Four

Five

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

Have the court(s) or the parties in the file determined cost-sharing? * *

Yes

No

Is financing secured for this service in order to provide a retainer? *

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

Have you reviewed the most recent Fee Schedule? *

Yes

No

Have you reviewed the sample Professional Services Agreement you would be expected to sign? *

Yes

No

Have you reviewed the sample Non-Disclosure Agreement you would be expected to sign? *

Yes

No

*

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