Law Offices of Kisha M.

Hebbon, LLC
Telephone (732)873-6464 Fax (732)873-6480
Email: kishahebbon@hebbonlaw.com
Website: www.hebbonlaw.com

CHILD CUSTODY INTAKE FORM

This form is extremely important. Your accuracy and completeness in responding will help
us best represent you. Please be sure to include street address, city, state, and zip code
when providing addresses and the month, day, and year when providing dates.

PERSONAL INFORMATION

NAME:_______________________________________________________________________
ADDRESS:____________________________________________________________________
HOME TELEPHONE:_______________________ CELL PHONE:_______________________
SS#:_________________________________ D.O.B.:_______________ AGE:______________
YOUR PLACE OF BIRTH (CITY AND STATE):_____________________________________
RACE:__________________________________ SEX:___________________
HEIGHT:_________ WEIGHT:_________ EYE COLOR:____________ HAIR COLOR:_____
YOUR DRIVER’S LICENSE NUMBER AND STATE OF ISSUANCE:___________________
MAKE, MODEL, AND YEAR OF YOUR CAR:______________________________________
AUTO LICENSE PLATE# AND STATE OF ISSUANCE:______________________________
STATE OF ISSUANCE: _________________________________________________________
CURRENT EMPLOYER:________________________________________________________
EMPLOYER ADDRESS:_________________________________________________________
EMPLOYER TELEPHONE NUMBER:_____________________________________________
NUMBER OF YEARS EMPLOYED:_______________________________________________
EDUCATIONAL BACKGROUND:________________________________________________
HEALTH COVERAGE FOR CHILDREN:___________________________________________
POLICY NUMBER:_____________________GROUP NUMBER:_______________________

OTHER PARENT’S INFORMATION

NAME:_______________________________________________________________________
ADDRESS:____________________________________________________________________
HOME TELEPHONE:_______________________ CELL PHONE:_______________________
SS#:_________________________________ D.O.B.:_______________ AGE:______________
HIS/HER PLACE OF BIRTH (CITY AND STATE):___________________________________
RACE:__________________________________ SEX:___________________
HEIGHT:_________ WEIGHT:_________ EYE COLOR:____________ HAIR COLOR:_____

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DRIVER’S LICENSE NUMBER AND STATE OF ISSUANCE:___________________
MAKE, MODEL, AND YEAR OF YOUR CAR:______________________________________
AUTO LICENSE PLATE# AND STATE OF ISSUANCE:______________________________
CURRENT EMPLOYER:________________________________________________________
EMPLOYER ADDRESS:_________________________________________________________
EMPLOYER TELEPHONE NUMBER:_____________________________________________
NUMBER OF YEARS EMPLOYED:_______________________________________________
EDUCATIONAL BACKGROUND:________________________________________________
HEALTH COVERAGE FOR CHILDREN:___________________________________________
POLICY NUMBER:_____________________GROUP NUMBER:_______________________

CHILD INFORMATION

FULL NAME D.O.B. AGE SS#

1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
4. ____________________________________________________________________________
5. ____________________________________________________________________________

HIS/HER PLACE OF BIRTH (CITY AND STATE):___________________________________

CHILD CUSTODY QUESTIONS

1. HOW LONG WERE YOU AND THE OTHER PARENT TOGETHER?

2. HOW OLD WAS THE CHILD WHEN YOU SEPARATED?

3. HAS THE OTHER PARENT SHOWN A WILLINGNESS TO AGREE,

COMMUNICATE, AND COOPERATE IN MATTERS RELATING TO THE CHILD?
PLEASE EXPLAIN YOUR ANSWER IN DETAIL.

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4. HAVE YOU SHOWN A WILLINGNESS TO AGREE, COMMUNICATE, AND
COOPERATE IN MATTERS RELATING TO THE CHILD? PLEASE EXPLAIN
YOUR ANSWER IN DETAIL.

5. PLEASE DESCRIBE YOUR INTERACTION AND RELATIONSHIP WITH YOUR

CHILD.

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6. PLEASE DESCRIBE THE OTHER PARENT’S INTERACTION AND
RELATIONSHIP WITH YOUR CHILD.

7. PLEASE DESCRIBE YOUR CHILD’S INTERACTION AND RELATIONSHIP WITH

HIS AND HER SIBLINGS.

8. IS THERE A HISTORY OF DOMESTIC VIOLENCE BETWEEN THE PARENTS OR

IN EITHER PARENTS’ HOME? PLEASE EXPLAIN.

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9. ARE THERE ANY CONCERNS ABOUT THE SAFETY OF THE CHILD WHILE
WITH THE OTHER PARENT OR WHILE IN THE OTHER PARENT’S HOME?
PLEASE EXPLAIN.

10. ARE THERE ANY CONCERNS OF EITHER PARENT ENDURING PHYSICAL

ABUSE BY THE OTHER PARENT? PLEASE EXPLAIN.

11. DOES THE CHILD HAVE A PREFERENCE WITH REGARD TO WHICH PARENT
HE OR SHE WANTS TO LIVE WITH? PLEASE EXPLAIN.

12. ARE YOU ABLE TO MEET THE NEEDS OF THE CHILD? PLEASE EXPLAIN.

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13. IS THE OTHER PARENT ABLE TO MEET THE NEEDS OF THE CHILD? PLEASE
EXPLAIN.

14. CAN YOU OFFER THE CHILD A STABLE HOME ENVIRONMENT? PLEASE
EXPLAIN.

15. CAN THE OTHER PARENT OFFER THE CHILD A STABLE HOME
ENVIRONMENT? PLEASE EXPLAIN.

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16. PLEASE DESCRIBE THE EDUCATION THE CHILD WILL RECEIVE IF HE OR
SHE LIVES WITH YOU. PROVIDE ALL INFORMATION ABOUT THE SCHOOL
HE OR SHE WILL ATTEND.

17. PLEASE DESCRIBE THE EDUCATION THE CHILD WILL RECEIVE IF HE OR

SHE LIVES WITH THE OTHER PARENT.

18. PLEASE PROVIDE A COMPARISON OF THE TWO SCHOOL DISTRICTS. I

SUGGEST DOING AN ONLINE SEARCH.

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19. DO YOU CONSIDER YOURSELF TO BE A FIT PARENT? PLEASE EXPLAIN.

20. DO YOU CONSIDER THE OTHER PARENT TO BE A FIT PARENT? PLEASE

EXPLAIN.

21. WHAT IS THE DISTANCE (MILES) BETWEEN YOUR HOME AND THE OTHER
PARENT’S HOME? HOW LONG DOES IT TAKE TO TRAVEL BETWEEN THE
TWO HOMES?

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22. HOW MUCH TIME HAVE YOU SPENT WITH THE CHILD AFTER HE OR SHE
WAS BORN?

23. HOW MUCH TIME DID THE OTHER PARENT SPEND WITH THE CHILD AFTER
HE OR SHE WAS BORN?

24. HOW MUCH TIME DID YOU SPEND WITH THE CHILD AFTER YOU AND THE
OTHER PARENT SEPARATED?

25. WHAT IS THE CURRENT PARENTING TIME SCHEDULE?

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26. HAS THE OTHER PARENT EVER INTERFERED WITH YOUR PARENTING TIME.
PLEASE EXPLAIN.

27. WHERE DO YOU WORK?

28. WHAT ARE YOUR WORK DAYS AND HOURS?

29. WHO WILL CARE FOR THE CHILD WHILE YOU ARE AT WORK?

30. WHERE DOES THE OTHER PARENT WORK AND WHAT IS HIS OR HER WORK
SCHEDULE?

31. WILL THE OTHER PARENT’S WORK RESPONSIBILITIES AFFECT HIS OR HER
ABILITY TO CARE FOR THE CHILD? PLEASE EXPLAIN.

32. PLEASE DESCRIBE THE HOME IN WHICH YOU CURRENTLY LIVE. PLEASE
INDICATE THE NUMBER OF BEDROOMS, THE SIZE, WHETHER THERE IS A
BACKYARD, WHETHER THERE IS A FINISHED BASEMENT, AND WHETHER
THE CHILD HAS HIS OR HER OWN BEDROOM.

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33. PLEASE DESCRIBE THE NEIGHBORHOOD IN WHICH YOU LIVE.

34. PLEASE DESCRIBE THE NEIGHBORHOOD IN WHICH THE OTHER PARENT

LIVES.

35. WHAT IS THE DISTANCE BETWEEN YOUR HOME AND THE SCHOOL YOUR
CHILD WILL ATTEND IF HE OR SHE LIVES WITH YOU?

36. WHAT PLAY FACILITIES ARE IN YOUR NEIGHBORHOOD?

37. ARE THERE ANY CHILDREN THE SAME AGE AS YOUR CHILD IN THE
NEIGHBORHOOD?

38. HOW IS THE CHILD CURRENTLY PERFORMING IN SCHOOL?

39. PLEASE LIST ANY PROGRAMS AND ACTIVITIES IN WHICH THE CHILD
PARTICIPATES:

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40. WHAT PROGRAMS AND ACTIVITIES DO YOU PARTICIPATE IN WITH THE
CHILD?

41. DOES THE OTHER PARENT PARTICIPATE IN ANY PROGRAMS AND

ACTIVITIES WITH THE CHILD? IF SO, PLEASE EXPLAIN IN DETAIL.

42. DO YOU HAVE ANY RELATIVES IN THE AREA? IF SO, PLEASE NAME AND
DESCRIBE THEIR RELATIONSHIP TO YOU AND THEIR INTERACTION AND
RELATIONSHIP WITH THE CHILD.

43. DOES THE OTHER PARENT HAVE ANY RELATIVES IN THE AREA HE OR SHE
LIVES IN? IF SO, PLEASE NAME AND DESCRIBE THEIR RELATIONSHIP TO
THE OTHER PARENT AND THEIR INTERACTION AND RELATIONSHIP WITH
THE CHILD.

44. DESCRIBE A TYPICAL DAY IN YOUR LIFE WITH THE CHILD (from waking up to
going to bed):

45. DOES THE CHILD LOVE THE OTHER PARENT? HOW DO YOU KNOW?

46. DOES THE CHILD LOVE YOU? HOW DO YOU KNOW?

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47. WHAT DO YOU AND THE CHILD DO TOGETHER?

48. WHAT TYPE OF CUSTODY DO YOU WANT? CHECK ALL THAT APPLY.

R JOINT LEGAL CUSTODY (BOTH PARENTS MAKING ALL MAJOR

DECISIONS REGARDING THE CHILD’S HEALTH, EDUCATION, AND
RELIGION).

R SHARED PHYSICAL CUSTODY (CLOSE TO 50/50 PARENTING TIME).

R YOU AS THE PARENT OF PRIMARY RESIDENCE AND THE OTHER

PARENT AS THE PARENT OF ALTERNATING RESIDENCE.

R SOLE LEGAL AND PHYSICAL CUSTODY WITH THE OTHER PARENT

NOT HAVING PARENTING TIME.

R THE OTHER PARENT HAVING SUPERVISED VISITS.

R OTHER CUSTODIAL ARRANGEMENT:

WHY?

49. WHY ARE YOU REQUESTING THE CUSTODY YOU CHECKED OFF ABOVE?

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 50. IF YOU ARE AWARDED CUSTODY, WHAT PARENTING TIME WOULD BE
AGREEABLE TO YOU FOR THE OTHER PARENT?

51. WOULD YOU ENCOURAGE AND FOSTER THE RELATIONSHIP BETWEEN THE
CHILD AND THE OTHER PARENT?

52. HOW WOULD YOU DO THAT?

53. IF THERE IS ALREADY A COURT CASE OPENED, PLEASE PROVIDE THE

DOCKET NUMBER AND COUNTY.

PLEASE PROVIDE US WITH COPIES OF THE FOLLOWING:

- ANY PRIOR COURT ORDERS

- ANY PRIOR MOTIONS FILED BY EITHER PARTY
- ANY EXHIBITS THAT YOU BELIEVE WILL SUPPORT YOUR POSITION
- ANY COURT NOTICES

RELOCATION QUESTIONS (only answer the following questions if you intend on relocating
with the child or children or if the other parent is attempting to relocate with the child or
children):

1. WHAT IS YOUR REASON FOR WANTING TO RELOCATE?

2. WHAT IS YOUR REASON FOR OPPOSING THE RELOCATION?

3. DESCRIBE THE PAST HISTORY OF DEALINGS BETWEEN YOU AND THE

OTHER PARENT AND BETWEEN THE OTHER PARENT AND THE CHILD:

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4. WILL THE CHILD RECEIVE EDUCATION, HEALTH AND SOCIAL
OPPORTUNITIES AT LEAST EQUAL TO WHAT IS AVAILABLE HERE?

5. DOES THE CHILD HAVE ANY SPECIAL NEEDS OR TALENTS THAT REQUIRE
ACCOMMODATION?

6. IF YES, ARE SUCH ACCOMMODATIONS OR ITS EQUIVALENT AVAILABLE IN

THE NEW LOCATION?

7. IS IT POSSIBLE TO DEVELOP A VISITATION AND COMMUNICATION

SCHEDULE THAT WOULD ALLOW THE NON-CUSTODIAL PARENT TO
MAINTAIN A FULL AND CONTINUOUS RELATIONSHIP WITH THE CHILD? IF
YES, EXPLAIN.

8. WHAT IS THE LIKELIHOOD THAT THE CUSODIAL PARENT WILL CONTINUE

TO FOSTER THE CHILD’S RELATIONSHIP WITH THE NON-CUSTODIAL
PARENT IF THE MOVE IS ALLOWED?

9. WHAT EFFECT, IF ANY, WOULD THE MOVE HAVE ON EXTENDED FAMILY

RELATIONSHIPS HERE AND AT THE NEW LOCATIONS?

10. WHAT IS THE CHILD’S PREFERENCE?

11. WILL THE CHILD BE ENTERING IN HIS OR HER SENIOR YEAR OF HIGH
SCHOOL? IF YES, HOW DOES THE CHILD FEEL ABOUT THE MOVE

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 12. DOES THE NON-CUSTODIAL PARENT HAVE THE ABILITY TO RELOCATE?

13. IF THERE IS ALREADY A COURT CASE OPENED, PLEASE PROVIDE THE

DOCKET NUMBER AND COUNTY.

PLEASE PROVIDE US WITH COPIES OF THE FOLLOWING:

- ANY PRIOR COURT ORDERS

- ANY PRIOR MOTIONS FILED BY EITHER PARTY
- ANY EXHIBITS THAT YOU BELIEVE WILL SUPPORT YOUR POSITION
- ANY COURT NOTICES

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PLEASE PROVIDE ANY ADDITIONAL INFORMATION YOU FEEL I NEED TO KNOW:

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