Custody Evaluation Child Information Form - To be completed by each parent involved in the custody evaluation. Each parent complete one form per child involved in the custody evaluation.
HIPAA Privacy Notice - To be reviewed by each parent involved in the custody evaluation (this is to be kept for your records and does not need to be brought to the session)
Custody EvaluationConsent to Release Information - Gives consent for Dr. Belaire to interview and get records from third party individuals or organizations. One form should be completed by each parent for each of the following:
Court in which your case is managed (i.e. 19th JDC, etc.)
Parent’s attorney
All doctors the parent has seen in the last 10 years
All doctors each child has seen in the last 10 years
All counselors each parent has seen
All counselors each child has seen
Each child’s school and/or daycare
Anyone else Dr. Belaire needs to interview
Separate consent forms are needed for each family member for each professional (i.e. mother’s attorney, mother’s doctor, father’s attorney, father’s doctor, child 1’s doctor, child 1’s school, child 2’s doctor, child 2’s school, etc.). Do not combine multiple family members on one form. Do not include more than one third party individual/organization on one form. You will need to print multiple copies of this form.