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The Department of Justice Canada works to reduce family violence in Canada. Learn more...

Post-Separation Visitation Disputes: Differential Interventions

BACKGROUND PAPER

(2001-FCY-6)

APPENDIX 7: CHILDREN'S LAWYER INTAKE FORM

I. GENERAL INFORMATION

Has the Office of the Children’s Lawyer (previously the Official Guardian) ever been involved with you, the other party and/or your child(ren)?

  • Yes
  • No

If yes, when? DD/MM/YY

II. INFORMATION ABOUT YOURSELF

Name:

  • Last
  • First

Date of Birth: DD/MM/YY

Previous Name (if any):

  • Last
  • First

Place of Birth: (if not born in Canada)
Date of Arrival in Canada DD/MM/YY

Address:

  • No.
  • Street
  • City
  • Province
  • Postal Code

Telephone No.

  • Home
  • Work:
  • Fax No.

Lawyer’s Name (or contact person):

  • Last
  • First

Firm:
Address:

  • No.
  • Street
  • City
  • Province
  • Postal Code

Telephone No.
Fax No.

Are you employed?

  • Yes
  • No

What is your annual income? $

If yes, Business Name:
Address:

  • No.
  • Street
  • City
  • Province
  • Postal Code

III. INFORMATION ABOUT OTHER PARTY

Name:

  • Last
  • First

Date of Birth: DD/MM/YY

Previous Name (if any):

  • Last
  • Frist

Place of Birth: (if not born in Canada)
Date of Arrival in Canada DD/MM/YY

Address:

  • No.
  • Street
  • City
  • Province
  • Postal Code

Telephone No.

  • Home
  • Work:
  • Fax No.

Lawyer’s Name (or contact person):

  • Last
  • Frist

Firm:
Address:

  • No.
  • Street
  • City
  • Province
  • Postal Code

Telephone No.
Fax No.

Is the other party employed?

  • Yes
  • No

What is the annual income? $
If yes, Business Name:
Address:

  • No.
  • Street
  • City
  • Province
  • Postal Code

IV. SOME GENERAL QUESTIONS

  • 1. May we telephone you at work?

    • Yes
    • No

  • 2. I am:

    • Mother
    • Father
    • Maternal Grandmother
    • Maternal Grandfather
    • Paternal Grandmother
    • Paternal Grandfather
    • Other (specify relationship with child(ren):

  • 3. I am:

    • Applicant / Petitioner
    • Respondent / Defendant

  • 4. I am asking the court to make one or more of the following order(s):

    • sole custody of the child(ren)
    • joint and/or shared custody of the child(ren)
    • access to the child(ren) by
      • specified:
      • unspecified (e.g. generous and liberal access):
    • supervised access to the child(ren) by
    • no access to the child(ren) or termination of existing access by
    • an order that the other party be prevented from molesting, annoying or harassing me or the child(ren)
    • an order that the other party be restrained from removing the child(ren) from the jurisdiction
    • contempt order against other party(ies)
    • support for me
    • support for the child(ren)
    • variation of child support
    • termination of support arrears
    • exclusive possession of the matrimonial home
    • division of property
    • an assessment under s.30 of the Children’s Law Reform Act
    • mediation under s.31 of the Children’s Law Reform Act
    • costs
    • other (specify):

  • 5. Has there been any previous court order(s) dealing with custody
    and/or access issues?

    • Yes
    • No

    If yes, please attach a copy of the order(s).

  • 6. Relationship Status (to the other party):
    Date of Marriage or Relationship (commencement):
    DD/MM/YY

    Date of Separation:
    DD/MM/YY

    Presently, are you and the other party residing in the same premises:

    • Yes
    • No

    Separation Agreement:

    • Yes (attach copy)
    • No (attach copy)

V. INFORMATION ABOUT YOUR CHILD(REN)

  • 1.Name of Child:

    • Last
    • First

    Sex:

    • M
    • F

    Date of Birth: DD/MM/YY

    Briefly describe the time this child spends with each parent/person involved, i.e. day time only, overnight, location, etc.
    Does this child attend:

    • School:
      • Yes
      • No
    • Daycare:
      • Yes
      • No
    • Grade:

    Does this child have any special health/education needs?

    • Asthma:
      • Yes
      • No
    • Learning difficulties:
      • Yes
      • No
    • Bed wetting:
      • Yes
      • No
    • Does not eat:
      • Yes
      • No
    • Poor concentration in school:
      • Yes
      • No
    • Heart problems:
      • Yes
      • No
    • Allergies:
      • Yes
      • No
    • Other:
      • Yes
      • No

  • 2. Name of Child:

    • Last
    • First

    Sex:

    • M
    • F

    Date of Birth: DD/MM/YY

    Briefly describe the time this child spends with each parent/person involved, i.e. day time only, overnight, location, etc.
    Does this child attend:

    • School:
      • Yes
      • No
    • Daycare:
      • Yes
      • No
    • Grade:

    Does this child have any special health/education needs?

    • Asthma:
      • Yes
      • No
    • Learning difficulties:
      • Yes
      • No
    • Bed wetting:
      • Yes
      • No
    • Does not eat:
      • Yes
      • No
    • Poor concentration in school:
      • Yes
      • No
    • Heart problems:
      • Yes
      • No
    • Allergies:
      • Yes
      • No
    • Other:
      • Yes
      • No

[Please attach a separate sheet if there are more children]

VI. OTHER IMPORTANT INFORMATION

  • 1. a) ASSESSMENT

    • Is there an assessment being done or has an assessment been completed dealing with parenting issues and/or custody of and access to your children?

      • Yes
      • No

      If yes, by whom:
      Name:

      • Last
      • Frist

      Address:

      • No.
      • Street
      • City
      • Province
      • Postal Code

      Telephone No.
      Fax No.
      If assessment completed, attach copy.

    • b) MEDIATION

      Is mediation being conducted or has mediation been completed?

      • Yes
      • No

      If yes, by whom:
      Name:

      • Last
      • Frist

      Address:
      • No.
      • Street
      • City
      • Province
      • Postal Code

      Telephone No.
      Fax No.
      Attach copy.of mediation report if you have it

  • 2. CHILDREN’S AID SOCIETY INVOLVEMENT

    Has a Children’s Aid Society ever been involved with your family?

    • Yes
    • No

    Which Children’s Aid Society(ies)?
    When: DD/MM/YY

    What were the concerns?

    • neglect
    • physical abuse
    • sexual abuse
    • other (specify)

    Is CAS still involved?

    • Yes
    • No

    Do you agree that the CAS release information about yourself to use?

    • Yes
    • No

    Was there a court proceeding?

    • Yes
    • No

    Is it still going on?

    • Yes
    • No

    What was the result of that proceeding? (specify):

  • 3. VIOLENCE/ABUSE

    • a) Was there violence/abuse in your relationship with the other party?

      • Yes
      • No

      If yes, how often did the child(ren) hear or see this violence/abuse?

      • Never
      • Sometimes
      • Often

    • b) Was there violence/abuse against your child(ren)?

      • No
      • Yes

VII. INFORMATION ABOUT HELPING YOUR CHILDREN

  • 1. Describe your relationship with the other party. (Please print or write legibly)

  • 2. Please tell us your concerns about custody of and access to
    your child(ren). (Please print or write legibly)

  • 3. How Do you think we can help your child(ren)? (Please print or write legibly)

The following information would be very useful in helping us to understand circumstances your child(ren) are coping with.

VIII. ADDITIONAL INFORMATION

  • 1. Has a court ever made a restraining order against you or the other party?

    • Yes
    • No

    If yes, when: DD/MM/YY

    Have you or the other party ever signed a peace bond?

    • Yes
    • No

    If yes, when: DD/MM/YY

    Is there any information about criminal charges that we should know about?

  • 2. Is there any information about mental health issues that we should know about?

    • Depression
      • Yes
      • No
    • Manic depression
      • Yes
      • No
    • Crazy
      • Yes
      • No
    • Psychotic
      • Yes
      • No
    • Schizophrenic
      • Yes
      • No
    • Bi-polar
      • Yes
      • No

  • 3. Is there any information about drug, alcohol or other substance abuse that we should know about?

    • Drugs
      • Yes
      • No
    • Alcohol
      • Yes
      • No
    • Other substances
      • Yes
      • No

IX. INFORMATION ABOUT THE COURT CASE

Where has the court action been brought?

  • Ontario Court (Provincial Division)
    Court File No.
  • Ontario Court (General Division)
    Court File No.
  • Ontario Court (General Division) Family Court
    Court File No.

Address of Court:

  • No.
  • Street
  • City
  • Province
  • Postal Code

Telephone No.
Fax No.

Next Court date: DD/MM/YY
no fixed return date

Nature of next court proceeding:

  • case conference
  • settlement conference
  • motion
  • pretrial
  • trial
  • other

Name of court proceeding:

  • Applicant / Petitioner
  • Respondent / Defendant

X. USE THIS PAGE FOR ANY OTHER INFORMATION

I certify that I have reviewed the above information and that I believe it to be accurate.
Date: DD/MM/YY
Signature of Party:

[Please attach additional pages, as required, and fax this form
(416-314-8050) to us or send by mail]

Date Modified: 2012-08-03
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Important Notices