Chapter 18 - EXHIBIT 18B • PARENT SELF-REPORT

• Jurisdiction: Colorado

EXHIBIT 18B • PARENT SELF-REPORT

PARENT SELF-REPORT (PSR)

Name:
Other Names Known By:
Address:

Relationship to Child[ren]:

Home Telephone:
Birthdate: SSN:
Attorney's Name:

Work Telephone:
Education Completed:
Court Docket #:

Minor children to be included in the evaluation:

Name Birthdate Age School Grade Currently Living With

Other minor children related to the case, or living in the household:

Name Birthdate Age School Grade Child's Parents

Other adults related to the case, or living in the household:

Name Age Relationship to You Relationship to Each Child

1. How long have you known the other party in this case? When did your relationship/marriage begin? When did you separate?

2. Have you seen a counselor/therapist/religious advisor about issues in this relationship/marriage during the past five years? If so, whom:

Over what period of time?

3. Have any of the children seen a counselor/therapist/religious advisor about their feelings concerning this relationship/marriage? If so, whom:

Over what period of time?

4. If you have been in a doctor's care over the past five years, please provide your doctor's name, phone number and address. Indicate which, if any, medications you take regularly.

5. Who have been your children's pediatricians?

6. What health, emotional or learning problems do your children have?

7. What are your biggest concerns about the other party in this case as a parent?

8. Do you have any concerns about the children's physical or emotional safety while they are in your, or the other parent's, household?

9. What was your family of origin like? Please include information about your parents and siblings while you were growing up.

10. Who would you like the Child and Family Investigator to contact about you as a parent (you may list up to two people):

Person 1:
Name:
Address:

Relationship to you:
Home telephone:
Work telephone:

How long have you known this person?

How do they know about your parenting skills?

Person 2:
Name:
Address:

Relationship to you:
Home telephone:
Work telephone:

How long have you known this person?

How do they know about...