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Custody Evaluation Forms

Instructions:

Click on the links below to print each form.  Complete the forms and bring them to your first session.

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1. Custody Evaluation Parent Information Form - To be completed by each parent involved in the custody evaluation.
2. 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. 
3. Custody Evaluation Additional Interview Form - To be completed by each additional person interviewed in the custody evaluation
4. Custody Evaluation Fee Schedule and Declaration Statement - To be signed by each parent involved in the custody evaluation
5. 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)
6. HIPAA Privacy Notice Signature Form – To be signed by all adults attending counseling
7. Custody Evaluation Consent 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.