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Parent Coordination Questionnaire

Please complete the entire questionnaire form below and click on the "Submit Questionnaire" button.  All of the data submitted will only be used by the Parent Coordinators, Felicia Gledhill and Beverly Wilusz.


First Name Last Name
Address
City State Zip
Home Phone Work Phone
Cell Phone Best Number to Reach You
Home    Work    Cell
Best Time and Place to Contact You
Email


Divorce Information
Is This a Pre or Post Divorce Consultation?  
Pre Divorce Consultation
Post Divorce Consultation
If Post, Date of Divorce
If Pre, What is the Anticipated Time Before the Divorce is Final?
Judge's Name Attorney
Attorney's Address
City State Zip
Attorney's Phone Number


What Year Did You Get Married?
What Year Did You Separate?
What Year Did You Get Divorced?


Name(s) and Age(s) of Child/Children Including Date of Birth:
(List in Chronological Order with Oldest Child First)
Name Age DOB



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Section I: The Divorce - And Beyond
A.  Who Initiated the Divorce/Separation?  
Husband
Wife
Mutual Decision

Please Explain:


B.  On the Following Continua, Please Note Your Pre/Post-Divorce Relationship With Your Ex at Each Point in Time:
NOTE: If the specific duration(s) do NOT apply, please select "N/A"
Extremely
 Hostile		 Hostile
Angry		 Moderately
Cold		 Civil But
Friendly		 Very
 Friendly		 Not
Applicable
During The
First Year

During The
Second Year
Between Two & Four Years
After Five Years


C.  To What do you Attribute the Change in Your Relationship Over the Years? Check All That Apply and Explain Below:
The Passage of Time Education Regarding the Effects of Divorce
The Need to Co-Parent Change in My Financial Status
The Children Getting Older Change in My Ex's Financial Status
Child(ren) Leaving Home Change in the Children's Life
A Particular Incident or Crisis Started Job/Launched a Career
Realizing My Ex was "Good" with Children Different Job/Career
Personal Growth Involvement in Outside Activity 
Individual Therapy Making New Friends
Family Therapy Membership in a Support Group
Influence of Clergy Influence of Other Post-Divorced Couples
Pressure From My Own Parents My Remarriage
A New Love Interest Other
My Ex's Remarriage

Explain the Above Selections and Make any Additional Comments Here:



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Section II: Custody and Parenting Time
A.  Who is or What Would you Prefer to be Your Legal Custody Agreement?  
Joint Sole Custody Mother Sole Custody Father

 

B.  How Does That Work Out in Actual Parenting Time? Describe "Visitation" or Living Arrangements Below:   


C.  How Have the Schedule and Living Arrangements Changed as the Children Grow Older? Was it Because Their Needs, or Your Spouse's Needs Changed?  Please Explain:  



D.  What Issues, Events, or Situations Cause(d) Problems When You and Your Ex Share Parenting Responsibilities?  
Who Pays for What Putting Children's Needs First
Pick-Up/Drop-Off Time Making Decisions About School
Different Standards (e.g., cleanliness) Buying Necessities For Kids
Discipline Buying Gifts For Kids
Curfew Stepparent or Live-In
School Performance Wanting More Flexibility
Last Minute Changes in Schedule Attendance at School Functions
Relationships with In-Laws (grandparents) Activities in Which Your Ex Involves 
      the Children
Your Ex's Personal Habits (e.g. drinking) Crisis Management (e.g., the child has 
      a problem)
Religious Difference Division of Parenting Time
Different Ideas About Health Your Ex's Dating Habits
Which is Primary Residence
Things That Bothered You When 
      You Were Married

Please Explain the Above Selections in Greater Detail. Mention Whether the Difficulty Still Exists and Include Any Problem Areas Not Cited Above.  




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Section III: Working as a Co-Parent With Your Ex
For each of the following statements: (1) Rate yourself by indicating frequency of occurrence: "never", "rarely", etc. (2) In the boxes provided, explain or make more detailed comments about your rating. (3) Describe how your situation has changed over time since you were first separated or divorced. Use an additional piece of paper, if necessary, to add whatever thoughts come to mind as you are completing Section III. (Remember to label your comments "III-A," "III-B", etc.) ALL FIELDS ARE REQUIRED ON THIS ONLINE FORM.


A.  Even When my Ex and I Disagree on a Personal Level, I am able to Put Aside our Differences to Deal with the Children.
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

B.  Although my Physical and Mental Health are Vital Parts of my Ability to be a Parent, my Children's Needs Come First.
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

C.  I Respect my Ex as a Parent.
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

D.  When it Comes to "Milestone" Events, Like Birthdays and Graduations, my Ex and I can Attend a Joint Celebration.
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

E.  We Can Plan a Joint Celebration.
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

F.  If I Don't Agree With my Ex's Standards or Approach to Child Rearing, I Can Accept That We're Different.
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

G.  I Communicate With My Ex About What Happens When Our Child(ren) is With Me.
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

H.  I am able to Step Out of "Traditional" Gender Roles When Necessary (e.g. A Mother Fixes a Bike, A Father Cooks Dinner).
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

I.  I Restrain Myself From Talking Badly About My Ex in Front of the Children.
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

J.  If I Have Something to Communicate to My Ex Even if it's About the Child(ren), I Don't Ask Them to Convey the Message.
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

K.  I Respect the Power of Change in Our Family Life, and I Try to Anticipate the Effect of the Big Changes (Remarriage) or Transitions (Going to a New School). 
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

L.  No Matter What I Think of My Ex, I Know it's Important That He/She is in My Child(ren)'s Life. 
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

M.  I Believe That As Long As We're Both Still Alive, My Ex and I Will Always Be "Kin" - Connected Through Our Children. 
Never Rarely Sometimes Usually Always Almost Always

Explain:

 

N.  I Think It's Important For The Children to Maintain Contact With Their Grandparents No Matter What I Think of Them or of My Ex.

  
Never Rarely Sometimes Usually Always Almost Always

Explain:


 



Arcadia Counseling
228 Brooks Street SE
Fort Walton Beach, Florida 32548
Phone: (850) 301-0446
Fax: (850) 301-0442
Email: felicia@arcadiacounseling.com
          beverly@arcadialcounseling.com