Intake Form for Co-Parenting/Parenting Counseling
Central Counseling Services offers a 4-week (8 units) Co-parenting class. We have classes running monthly. Our Co-parenting classes are unique as we tailor each class to the participants' needs and provide you with "real" solutions that work to help you co-parent better.
Name: *
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Todays Date:
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Date of Birth:
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Address:
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City:
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Zip Code:
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Home Phone:
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Work Phone:
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Cell Phone:
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Employer:
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Marital Status:
If divorced, for how long?
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Attorney:
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Phone Number:
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Referred by:
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Insurance Billing:
If yes, please list insurance:
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Court Ordered:
If yes, how many hours/sessions?
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Names of children and their ages:
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1. Describe what is motivating you to pursue co-parenting/parenting counseling at this time:
Your answer
2. Describe the goals you wish to pursue in co-parenting/parenting counseling:
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3. What do you feel you most significant challenges are in achieving your stated goals?
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4. What has your past experience been with counseling (if any)?
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5. Describe what you see to be your strengths and your weaknesses?
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6. Briefly describe your past relationship with the other parent:
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7. Describe your relationship with the other parent currently:
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8. How do you attempt to communicate with the other parent at this time?
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