| DETAILED HISTORY QUESTIONAIRE A. IDENTIFYING DATA DATE:______________________________________________________________ Case Name and Number:__________________________________________________________________ Your Present Name:______________________________________________________________________ Your Age:_____________ Date of Birth:_____________________________ Your Place of Birth:______________________________________________ Your Religion:____________________________________________________ Your Home Address:______________________________________________ _________________________________________________________________ Your Home Phone No.__________________ Your Soc. Sec. #____________________ Fax No._________________________ Cell Phone No.___________________________ B. EMPLOYMENT Employer:________________________________________________________ Type of Employment_____________________________________________ Length of Employment:___________________________________________ Address:_________________________________________________________ Phone No.:___________________ Work Hours:_____________________ If you travel for employment, please describe:____________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ C. YOUR CHILDREN INVOLVED IN THIS CUSTODY CASE Name Age Birthdate School/Grade ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________________________ YOUR OTHER CHILDREN (not involved in this court case) Name Age Birthdate School/Grade ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________________________ Children’s Personality and Special Emotional or Physical Needs (For each child involved in this case, describe your child as you would to a stranger. Then discuss any physical or educational disability, emotional or behavioral problems, history of psychotherapy or psychiatric care, special talents or interests that may affect custody arrangements. ________________________________________________________________________________________ ________________________________________________________________________________________ ___________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________________________________ Brief school history for each child (performance, social adjustments, grade level, etc. Please attach the latest school report card for each child. child.): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ D. PHYSICAL AND LEGAL CUSTODY HISTORY OF CUSTODY AND VISITATION AGREEMENTS AND ORDERS UP TO THE CURRENT COURT ORDER/CUSTODY PLAN (Please attach a copy of all past and current agreements and court orders regarding custody and visitation to this questionnaire): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ YOUR REQUESTS REGARDING PHYSICAL CUSTODY (Please include a proposal for an exact schedule with times and place of exchange; if you would like a different schedule during the school year and summer school break, please state those separately): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ YOUR REQUESTS INVOLVING LEGAL CUSTODY (how should parents communicate and make decisions about health care, education, religion, activities, psychotherapy, etc.): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ YOUR REQUESTS FOR A HOLIDAY, SCHOOL BREAK, AND VACATION SCHEDULE (include Thanksgiving, New Years Eve, New Years Day, 4th of July, Mother’s/Father’s Day, Winter Break, Spring Break, all national holidays on Friday or Monday, and relevant religious holidays such as Christmas Eve, Christmas Day, Hanukkah, Passover, Easter, etc.) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ YOUR REQUESTS FOR COUNSELING AND/OR ANY OTHER TYPES OF ORDERS IN THIS CASE: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ EXPLAIN THE REASONS FOR YOUR CUSTODY REQUESTS: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ E. MARITAL AND RELATIONSHIP HISTORY List all the dates of previous marriages and whether children from previous marriages: _________________________________________________________________ _________________________________________________________________ Are you remarried: YES____________ NO____________ If Yes, please give name (and ask spouse to complete stepparent questionnaire): _________________________________________________________________ If No, are you in a relationship: YES_______ NO_______ If Yes, please give name and age of person and describe your relationship (dating, committed, engaged, etc.) and how much time you spend together and how much time that person spends around the children: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Describe Marital History with Former Spouse in Dispute With: Met (when, where), Relationship Before Marriage: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Married (when and where): _________________________________________________________________ _________________________________________________________________ Responsibility for Care of Children During Marriage (include child care providers and description of parents employment during that time): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Separated from Former Spouse (when and why):__________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Living Arrangements for Parents and Children after Separation and First Arrangements for Children Spending Time with Each Parent: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Were there any restraining orders requested or issued? If yes,describe: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ F. YOUR BACKGROUND AND FAMILY OF ORIGIN Where Born and Raised:__________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ If you were born in another country, when and why did you immigrate to the U.S. and when did you receive your permanent residency and/or citizenship? _________________________________________________________________ _________________________________________________________________ ________________________________________________________________________________________ __________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Your Mother: (Describe her occupation and your relationship with her when you were growing up and your relationship with her now. Where does she now live and is she involved with your children?) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Father: (Describe his occupation and your relationship with him when you were growing up and your relationship with him now. Where does he now live and is he involved with your children? _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Your siblings (age, where do they live, how often do you see them and/or talk to them?) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Describe the family you grew up in (your parents relationship, who took care of the children, how you had fun together, who was close to each other, how your parents disciplined, how conflict got resolved, significant events or problems that affected your upbringing.) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Describe any Alcohol Abuse, Drug Abuse, Arrests/Criminal History, Psychiatric History (prescribed psychiatric medication, psychiatric hospitalization, suicidal behavior) in members of your Family of Origin, and how it affected you. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ G. PERSONAL DATA: Education (give highest degrees, and area of study): _________________________________________________________________ _________________________________________________________________ Work History (briefly describe the kinds of occupations you have had and how long you have worked at your last three positions): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Military History (describe the type of duty and whether you were in combat): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Medical History: _____________________________________________ _________________________________________________________________ _________________________________________________________________ Current Prescribed Medication (and the condition for which is it prescribed: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Psychiatric History (consultation with a psychiatrist, psychiatric hospitalization, suicidal behavior, eating disorder, psychosis, If you have had a psychiatric hospitalization, please provide the hospital records records): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Have you ever taken any of the following medications: YES NO a) Prozac (fluoxetine) ____ ____ b) Wellbutrin (buproprion) ____ ____ c) Anafranil (clomipramine) ____ ____ d) Norpramin/Pertofreane (desipramine) ____ ____ e) Pamelor (nortriptyline) ____ ____ f) Buspar (buspirone) ____ ____ g) Tegretol (carbamazepine) ____ ____ h) Depakote/Depakene (valproic acid) ____ ____ I) Desyrel (trazodone) ____ ____ j) Asendin (amoxapine) ____ ____ k) Xanax (alprazolam) ____ ____ l) Klonopin (clonazepam) ____ ____ m) Other psychiatric medication_______________________________ _________________________________________________________________ Alcohol/Drug Use. (If you have been in a drug or alcohol treatmentprogram, please provide the hospital or clinic records)Have you ever experimented with or used the following substances: YES NO a) Alcohol, more than 8 drinks in a day ____ ____ b) Marijuana or cannabis in other forms ____ ____ c) Cocaine ____ ____ d) Amphetamines ____ ____ e) Barbiturates ____ ____ f) Hallucinogens ____ ____ g) Prescription pain medication ____ ____ If Yes, to any of above about alcohol/drug use, please give information about first use, how long you used, and last use. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Psychotherapy including Marital Therapy: (reasons for treatment, names and phone numbers for psychotherapists, and dates of treatment) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ History of Arrests (for whatever reason), DUI violations, Criminal Prosecution, Dishonorable Discharge from Armed Forces ( If there is a history of any of the above, provide police, court, DMV, probation, discharge records) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ H. ISSUES AND CONCERNS IN THE CURRENT CASE History of any domestic violence (including specific incidents. Provide any police reports or restraining orders) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ History of any involvement of Department of Children and Family Services (Give dates of reports and investigations, names and phone numbers of investigators Provide any paperwork you have on case and/or arrange for your attorney to subpoena the file from DCFS) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Concerns you may have about your former spouse that relate to your custody requests (such as irresponsibility, poor parenting, psychiatric problems, sexual abuse, reckless behavior, drug abuse, alcohol abuse,): _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Your understanding of the concerns and issues your former spouse has about you, as they relate to his or her custody requests. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Your understanding of the children’s thoughts and feelings about their custody arrangement and any concerns they have about the parents. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ I. STEPPARENT OR OTHER HOUSEHOLD MEMBER INFORMATION: If you have remarried or if you now share or plan to share your home with another adult, please complete the following questions in regard to the other adult. Name:___________________________________________________________ Age: _______ Phone No.______________________________________ Occupation_____________________________________________________ Relationship to You:______________________________________________ _________________________________________________________________ _________________________________________________________________ Names and ages of this person’s children: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ This Person’s Relationship with the Child/Children at Issue: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ |
| Law Offices of Warren R. Shiell |
| Please call to make an appointment: Tel: (310) 247-9913 |
| 9935 South Santa Monica Blvd. Beverly Hills, CA 90212 |