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Submitted on Oct 23, 2026 at 6:00 AM GMT+0000

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Parenting Coordination Intake

Individual intake form to be completed separately by each parent for Parenting Coordination.

Your Name^*

Address^*

Country

Street address

Apartment, suite, etc.

Phone^*

Email^*

Attorney Name^*

Attorney Phone / Email^*

How did you hear about us?^*

Children^*

Pediatrician / Medical Provider^*

Mental Health Professional^*

School^*

Child Care Provider^*

Other^*

Year Married, if applicable^*

Year Separated^*

Year Divorced, if applicable^*

If you were never married, briefly describe the history of the parenting relationship^*

How long have the current co-parenting concerns been present?^*

Have you consulted with other professionals regarding these concerns? If yes, please identify the professional(s) and briefly describe the outcome.^*

Is there a history of domestic violence, threats, stalking, harassment, coercive control, restraining orders, or other significant safety concerns between the parents? Please explain.^*

Who currently lives in your home?^*

Who is part of your support system?^*

Who is part of your child(ren)'s support system?^*

Are extended family members significantly involved with the child(ren)? If yes, please explain.^*

How are parenting responsibilities currently shared?^*

How would you describe the current co-parenting relationship?^*

What are the primary areas of disagreement or conflict between you and the other parent?^*

What communication methods are currently used between the parents? What works well and what does not?^*

What is the current time-sharing arrangement?^*

Is there a current Parenting Plan or Court Order governing parenting responsibilities? If yes, briefly identify the current arrangement.^*

Has the parenting or time-sharing arrangement changed over time? If yes, please explain.^*

What concerns do you have regarding the current parenting arrangement?^*

What specific issues would you like assistance addressing through Parenting Coordination?^*

What changes would you like to see as a result of the Parenting Coordination process?^*

What would tell you that the Parenting Coordination process has been useful?^*

Are you currently attending individual or family therapy?^*

Yes

Therapist / Provider Name^*

Telephone / Email^*

Please identify any additional information you believe would be important for the Parenting Coordinator to understand at the beginning of this process.^*

I certify that the information provided in this intake form is true and complete to the best of my knowledge. I understand that this form is intended to assist the Parenting Coordinator in understanding the family and the issues presented for Parenting Coordination.

Printed Name^*

Date^*

Signature^*

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