OAKLAND COUNTY FRIEND OF THE COURT

CUSTODY AND PARENTING TIME QUESTIONNAIRE

CASE# CASE NAME v TRIAL DATE

YOUR NAME DATE OF BIRTH

ADDRESS

PHONE# (HOME) (WORK) (CELL)

SOCIAL SECURITY # DRIVER'S LICENSE #

YOUR ATTORNEY’S NAME/ADDRESS/PHONE

OTHER PARENT’S NAME/ADDRESS/PHONE__________________________________________________________

YOUR CHILDREN: (List all your children, not just those involved in this dispute. Indicate if from a previous marriage or relationship)
Name Birthdate Grade Name of School

Please attach final report cards for last three years, if applicable.
YOUR FAMILY OF ORIGIN

Name Age Address Phone#

Your Father

Your Mother

Name/address/phone number of person who will always know your whereabouts

MARITAL HISTORY
Name of Current and all Former Spouses Date & Place of Marriage Date of Divorce/Death

If you are separated from the other parent, when did it occur? What was the main reason for the divorce

or separation from the other parent in this case?

EDUCATION AND EMPLOYMENT HISTORY

What grade/degree did you complete? Date of completion

Rev 11/01

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Where do you work? Job Title

Address of Employer Phone#

How long have you worked for this employer? Supervisor

What is your yearly gross income? Your weekly take home pay

Work hours Do you work overtime or travel out of town? Yes No If so, how many hours

per week Do you have plans to change job(s)? Yes No

If so, when? Name/address/phone of new employer

Other income (second job, ADC, Social Security, Disability, Unemployment benefits, another child support case etc.):

Source Amount per ( i.e. week, month, etc)

List all previous jobs you have had in the past 3 years in chronological order:
Employer Dates Worked Wages Reason for Leaving

Is any child support being paid? Yes No By whom? How much? per month

Is the child support current? Yes No If not, what is the arrearage owed?

Why does the arrearage exist?

What health insurance coverage does your child(ren) have?

Which parent has the health insurance coverage for your child(ren)?

Who has generally taken the child(ren) to the doctor or dentist?

Who has generally purchased the clothing for the child(ren)?

Who has generally arranged for child care for the child(ren)? Explain the child-care arrangements

that you are using at this time and/or plan to use in the future:
Name and phone # of your child(ren)’s day care provider(s):

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 RESIDENCE AND SOCIAL HISTORY

Current address and how long have you lived here?

Are you buying or renting? Amount of monthly payment: Who pays?

Who lives in this residence?

Name Age Relationship Name Age Relationship

How long has the current family unit lived together? Will there be any changes? Yes No If yes, explain

Describe your home (i.e. type, number of rooms, who sleeps in each bedroom)

Do you have plans to move from this residence? Yes No If so, when and where?

List all previous residences during the last three years:

Are you currently dating anyone on a regular basis? Yes No If yes, give the person’s name, address, marital status,
note any future plans for marriage, and describe the relationship this person has with your children:

Does the person you are dating on a regular basis have children? Yes No Doesn't Apply If yes, note the following:

Child(ren)'s name Birth date Current address of child(ren)

Do you have any problem with the current or proposed living arrangement of the other parent? If so, explain:

Are you, or the other parent, expecting another child? Yes No If so, who is expecting and what is the due date?

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What health problems do you have, if any?

Note the medicines you take and the reasons you are taking them:

What health problems does the other parent have?

With what frequency do you use alcohol or drugs?

With what frequency does the other parent use alcohol or drugs?

Did alcohol or drugs affect the relationship?

Was there any domestic violence in your relationship? (Describe)

Has any law enforcement agency ever been involved because of physical violence? If so, which one(s) and when?

(Please attach a copy of Personal Protection Order and/or police reports, if applicable)

Have you and/or the other parent been involved in individual or marriage counseling? Yes No

If yes, provide the following:

Have you or the other parent participated in any substance abuse treatment program? Yes No If yes, note who and give
name of program(s) and dates of service:

Have you, or the other parent, been arrested?Yes No If yes, note who was arrested, provide reason(s), date(s), and

location(s)

Have you and/or the other parent been convicted of driving under the influence of alcohol/other drugs, or any other traffic
violations or crimes? Yes No If yes, note who was convicted and provide the date(s), location, charge(s),
sentence, etc.

Have you, or the other parent, ever been investigated by Children’s Protective Services? Yes No
If yes, note who and provide the date(s) of the investigation, the location of the office and the worker’s name and phone#:

(Please attach a copy of the report, if available)

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 YOUR CHILDREN

How do you show love for your child(ren)?

What activities do you share with your child(ren)?

Who usually stays home from work with a sick child? What arrangements do you make for care of a sick

child or other emergency?

What responsibilities does your child(ren) have in your home?

How do you discipline your child?

Do you and the other parent agree on discipline? Yes No

What religion, if any, do you practice? What religious training does your

child(ren) receive? Which parent provides this?

What are your child care plans should your child(ren) live primarily with you?

What are your parenting strengths?

What are parenting strengths of the other parent?

What are your parenting weaknesses?

What are the parenting weaknesses of the other parent?

What special holiday traditions does your child(ren) have?

What holidays do you consider important?

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What is the present parenting plan?

Is it working?Yes No If no, describe the problems:

What do you think is the best custody and/or parenting plan for your child(ren)? Describe in as much detail as possible

when your child(ren) would be with you and when with the other parent:

What other plan(s) can you suggest?

If you are asking for custody of your child(ren), why do you think that you would be the better parent to have custody?

Describe your child(ren):

What are your child(ren)'s extracurricular activities?

What are your child(ren)'s special needs and the responsibilities you assume to meet them?

Has counseling been pursued for your child(ren)? Yes No If yes, note who and why and provide the counselor's name,

agency, phone number, and dates of service:

Anything you want to make the court aware of which could affect custody/parenting time?

Signature Date