information form of parent for guardian ad litem … information form for gal parents... · 707...

LARRY W. YARBROUGH ATTORNEY AT LAW

707 WHITLOCK AVE., SUITE E20 MARIETTA, GEORGIA 30064

(770) 427-8453 [email protected]

INFORMATION FORM OF PARENT FOR GUARDIAN AD LITEM

(Please feel free to attach additional sheets if more space is needed.)

PERSONAL INFORMATION: Name:

Current Address: Home Phone Work Phone:

Cell Phone: Fax Number:

Email address:

Date of Birth: Place of Birth:

Previous Addresses for past 10 years:

From To Address

EMPLOYMENT HISTORY: Current place of employment: Employer:

How Long with this employer:

Job Description:

Hours/ Days of employment:

Current Annual Income from this employment:

mailto:[email protected]

INFORMATION FORM FOR GAL PAGE 2

Other current source of income: Employer:

How Long with this employment:

Job Description:

Hours/ Days of employment:

Current Annual Income from this employment:

Previous employers/employment:

From To Employer Gross Annual Income

EDUCATIONAL HISTORY: High Schools (even if you did not graduate):

Dates Attended School Name Location Last

Grade Completed

College/University/Technical/Other:

Dates Attended Name Location Degree


Certificates/GED/Licenses/Other:

Date Issuing Agency/School Location Certificate

MEDICAL HISTORY: Please set out below any injuries, medical conditions, illnesses, psychological/psychiatric conditions, substance abuse, or addiction problems, past and present, which you have experienced or you are currently experiencing:

Dates Description

If you drink alcohol or use drugs (except as prescribed), what type, how much, and how often (usually)? Do you have past or present problems with the consumption of alcohol and/or drugs? ___________. If so, please set out the details:


Please provide the name, address, and phone number of any professional you have seen in the past 10 years, or are currently seeing, for illness, injury, medical condition, therapy, counseling, psychiatric, or psychological treatment. (For each please set out the reason for seeing the professional, the date you first saw the professional, the diagnosis if applicable, and how long you continued seeing the professional. Use additional sheet if necessary):

Dates Professional (Name & address) Reason/Diagnosis

Please list all medications you have taken in the past two years, including the dates taken, whether prescribed, and the reason for each medication:

Dates Medication Reason


CIVIC/RELIGIOUS ACTIVITIES: Name of religious organizations you attend, if applicable:

How often do you attend? Do(es) the child(ren) attend Are you a member of any civic, community groups, sports associations, and professional associations? If so, please describe them: What hobbies do you have? What charity work do you do? Activities you and the child(ren) enjoy together: Date and place of your most recent vacation with the child(ren):


RELATIONSHIPS (Marriages, etc.): Current Relationship, if applicable: Name: Type of Relationship (Marriage, lived together, etc.): Beginning date of relationship (date and location of marriage is applicable): : Ending date of relationship (date and location of divorce, if applicable) Children born of this relationship, if any.

Previous Relationships, if applicable: Name: Type of Relationship (Marriage, lived together, etc.): Beginning date of relationship (date and location of marriage is applicable): : Ending date of relationship (date and location of divorce, if applicable) Children born of this relationship, if any.

Name: Type of Relationship (Marriage, lived together, etc.): Beginning date of relationship (date and location of marriage is applicable): : Ending date of relationship (date and location of divorce, if applicable) Children born of this relationship, if any.


FAMILY HISTORY Your Parents: Name: Current Address: Home Phone : Email address: Age: If deceased, date of death:

Name: Current Address: Home Phone : Email address: Age: If deceased, date of death:


Your Stepparents, if applicable: Name: Current Address: Home Phone : Email address: Age: Married to:

If deceased, date of death:

Name: Current Address: Home Phone : Email address: Age: Married to:

If deceased, date of death:


Your brothers and sisters: Name:

Address:

Telephone:

Email address:

Age: :

Marital Status:

Children:

How often do you see him/her?

Name:

Address:

Telephone:

Email address:

Age: :

Marital Status:

Children:


Name:

Address:

Telephone:

Email address:

Age: :

Marital Status:

Children:


Name:

Address:

Telephone:

Email address:

Age: :

Marital Status:

Children:



CHILDREN INVOLVED IN THIS LITIGATION (one page per child; use additional sheets if needed) Child’s Full Name:

Child’s Date and Place of Birth Current School, if any, grade and teacher’s name Previous schools attended and dates of attendance:

Child Care Provider, if applicable (Name and address): List any disabilities of the Child’s , whether physical, mental or psychological: List the Child’s physicians, including the address and reason for consulting the physician. List any medications currently prescribed to the Child: Child’s extracurricular activities: (Please attach a recent photograph of this child)


Child’s Full Name:




Questions concerning the current case (use additional sheets if needed): Who do you believe should have primary custody of the Child(ren), and why Has there been any family violence incidents involving the child(ren), the parents of the child(ren) or any other family member? If so, please give details: Has the child (or children) expressed a preference as to custody? If so, please give details, including the date, time , and circumstances involved. Do you plan to move your residence more than 50 miles from your present residence? If so, why, when, and where to? Does this action involve allegations of Child Abuse or Alcohol/Drug Abuse? If so, explain:


Has either Parent been denied contact with the Child(ren) for any reason?. If so, please give details If you receive primary physical custody of the child(ren), will you be utilizing child care by other persons? If so, please explain the childcare plan:


WITNESSES (Attach additional sheets if necessary) [Please list names, addresses, work and/or home telephone numbers of witnesses (friends, relatives, business associates, neighbors, etc.) who know you well and can discuss your parenting skills, your character in general, and any other facts pertinent to the issues of child custody and visitation.] [ Please note that listing a witness here does not necessarily mean that witness will be contacted by the Guardian. If you have a witness who wishes to give the guardian information, please have that witness send a letter, fax, or (preferably) an email to the Guardian ad Litem at [email protected]. Such correspondence should reference your name and contain the information requested below, as well as facts and opinions concerning your parenting skills, your character in general, and any other facts pertinent to the issues of child custody and visitation.] Name: Address: Contact Numbers: Email address:

How long has this person known you? How does this person know you? Name: Address: Contact Numbers: Email address:

How long has this person known you? How does this person know you?


Name: Address: Contact Numbers: Email address:





CRIMINAL HISTORY For each arrest or major traffic ticket you have had in your lifetime, please list the date of arrest or ticket, State and County of arrest or ticket, the Court that handled the case, and the disposition of the case:

Date of incident

City, County, State

Charge

Disposition

Are you currently on probation or parole? If so, please give details: Are you aware of any current warrants for your arrest? If so, give details: Driver’s License Information: Driver’s License Number

Issuing State: Date of Issuance:

Have you ever had your license suspended? If so, give details: Is your license currently suspended? If so, why and when will it be reinstated?


Please review the following information. You will be asked to sign this document before a notary; therefore, it is important that you discuss any concerns you have about this form with your attorney prior to signing. 1) It is my understanding that I am to schedule an initial office visit with the Guardian ad Litem. Prior to that meeting, it is my responsibility to complete this form and forward it to the Guardian ad Litem. I understand that I am to contact his office at 770-427-8453 and schedule the initial office conference. I understand that I I need to provide this completed form before or at the time of that appointment, and if I have not provided the Guardian ad Litem with the completed form, he will not be able to see me at the appointed hour. 2) It is my understanding that during the time of the office visit, the Guardian may schedule a home visit with me and my children. If not, such a home visit will be scheduled later. 3) I understand that payment is to be made to the Guardian ad Litem pursuant to the Court's Order. I understand that I have an ongoing financial responsibility to the Guardian and that the Guardian's fees may exceed the initial retainer. I understand that the Guardian bills at the rate of $ 220.00 per hour (in 0.1 hour increments, which equates to six minutes or less). I understand that my attorney will receive regular statements detailing the Guardian's activities in my case. I understand that it is my responsibility to raise any questions I might have regarding my billing statement with the Guardian's bookkeeper. If the bookkeeper cannot resolve the problem, I understand that it is my or my attorney's responsibility to initiate a conversation with the Guardian about my bill. 4) I understand that the Court will most likely enter an Order or Orders requiring me to pay the Guardian ad Litem for his time in the investigation of this matter and the Order will state how long I have until the payment or payments is/are due. I understand that once such an Order has been entered, it is my obligation to fully comply with it. I understand that if I do not comply with the Court's Order, the Guardian ad Litem will file an Application for Citation for Contempt against me, in which the Guardian ad Litem will request that additional attorney's fees be paid for having to bring the Contempt action. I understand that the Guardian ad Litem may request other relief in the Application. 5) I understand that the Guardian is committed to assisting in the resolution of my case prior to final court hearing. If the case cannot be resolved, I understand that I or my attorney or the other party or their attorney may request a written report from the Guardian. In fact, I understand that some courts will not allow the attorneys to waive the writing of a report if a final trial is necessary. I understand that the report will take approximately six to twelve hours of the Guardian's time and that he will bill at his regular hourly rate for writing the report. 6) I understand that I have the right to contact the Guardian either by telephone, fax, email or regular mail during the pendency of the case. I further acknowledge that I understand that the Guardian frequently cannot return messages the same day and that it is in my absolute best interest to contact the Guardian's office and arrange telephone conferences or office appointments with the Guardian. I understand that I can do this as often as I like. 7) I understand that the Guardian is not the Judge. It is the Guardian's responsibility to make recommendations to the Court about my child or children's welfare. I understand that the Guardian's recommendations are not binding on anyone and that the Judge alone will decide any issues impacting me and my child or children. 8) I understand that it is my responsibility to have my references or witnesses contact the Guardian, preferably by email or regular mail, and that follow-up contact may thereafter be requested by the Guardian. I understand that if I want the Guardian to meet personally with a particular reference or witness, it is my responsibility to contact the Guardian's office to schedule a telephone or office appointment to do so. I understand that my references, witnesses and/or I are to speak with the Guardian or his staff to make an appointment with the


Guardian. I understand that if neither I nor my references or witnesses contact the Guardian's office, that the Guardian ad Litem will infer that I do not want him to meet personally with anyone regarding me or my children or the situation at hand. I understand that I can have as many appointments with the Guardian as I want, but it is my responsibility to schedule those appointments as I see fit or desire. 9) I understand that the Guardian ad Litem might bring a camera to my home on his visit and that he may photograph my children and my home. I also understand that the Guardian ad Litem may make audio and video recording of my communications with him to preserve the conversations we have. I understand that if the Guardian ad Litem is being required to travel out of town in his investigation of my case that he will not do so until adequate funds have been given to him against which he will apply the anticipated costs of the trip, e.g., airfare, rental cars, hotel rooms, and time required in his investigation. 10) I understand that the Guardian ad Litem has a responsibility to report allegations of child abuse to the Department of Family and Children Services (DFCS), should he find or believe that probable cause exists, and a report has not already been made by me or someone else. If a report has already been made to DFCS by me or a mandatory reporter, such as a school official, mental health provider, doctor, clergyman, or dentist, the Guardian ad Litem will not duplicate their efforts. It is my responsibility or the responsibility of my attorney to advise the Guardian ad Litem if a report has been made to DFCS and if DFCS has taken any action in response to that report. Furthermore, it is my responsibility or the responsibility of my attorney to obtain copies of any documentation from DFCS or corresponding police departments regarding the incident reported. This includes police reports, video tapes, and any statements that may have been given. I agree that it is not the Guardian's responsibility to pursue this information on my behalf. I also understand that if I believe that sexual or physical abuse has occurred where my children are involved, it is important for me to report my concerns to the Guardian at our first visit. I also understand that if there are allegations that my child has been sexually abused or physically abused, the Guardian will not interview the child on these issues as he is not trained forensically to do so. I understand that the Guardian will rely upon law enforcement and/or DFCS to conduct such interviews and that the Guardian may be present at these interviews. Additionally, if I suspect that my child has mental health issues or if my child has made suicidal gestures or threats, it is my responsibility to communicate this to the Guardian at Litem at our first visit. 11) I understand that I have the right to ask the Guardian any questions I might have about his procedure and his role in my case. It is my responsibility to raise these questions on this form, at the initial meeting with the Guardian ad Litem, and at any subsequent meeting with the Guardian. I will not hold the Guardian responsible for knowing information that I regard as critical that I do not provide to him. I also understand that the Guardian may not answer questions that he regards inappropriate to the situation, such as questions regarding the Guardian=s final recommendation. 12) I understand that I may be asked to execute releases to various service providers who see or have seen me or my children, and that these releases are most likely to be on forms supplied by the service provider. I acknowledge that I have discussed or will discuss with my attorney any such release of protected information prior to signing it, and that failure to sign such a release may hamper the Guardian=s investigation. 13) I understand that it is not the Guardian's responsibility to provide records, reports, documentation, recordings, etc. to any custody evaluator or other professional that may be involved in my case. It is my or my attorney's responsibility to provide copies of these documents directly to the other professionals in this case. 14) I understand that the Guardian is not my attorney and that he will not give me legal advice. I acknowledge that I should address any legal questions I have with my attorney or some other appropriate individual and not with the Guardian. 15) I understand that it is my responsibility and that of my attorney to keep the Guardian ad Litem advised of any changes in my status or that of my children during the pendency of this action. This includes, but is not


limited to, a change in my address, a change in my employment, a change in my telephone number(s), a serious change in my health, a change in my marital status (if this action is not a divorce), a change in my legal status (e.g., an arrest during this case), a change in where my child attends school, a change in my child's legal status (such as Juvenile Court offenses that might arise), and a change in my child's health (including suicidal gestures. serious illnesses, hospitalizations). If this is a modification action or any other action wherein I am not married to the other parent, it is my obligation to arrange for the Guardian ad Litem to meet my significant other or new spouse; it is not the Guardian ad Litem's obligation to make these arrangements. 16) I understand that the Guardian ad Litem may run into procedural issues involved in my case which have not been encountered in any previous case in which the Guardian has been involved. I understand that the Guardian ad Litem will attempt to resolve these issues with me or, if I am represented by counsel, with the attorney representing me. It may, however, become necessary for the Guardian to consult the Judge's staff as to how certain issues should be resolved and that the Guardian may request a pre-trial conference with the Judge, with attorneys present, to resolve an issue. It is my responsibility to discuss this paragraph with my attorney prior to my signing this form, if I have an attorney. Should I or my attorney have any concerns regarding this paragraph, it is our responsibility to immediately initiate a discussion with the Guardian on this point. 17) I understand that I am to bring no tape recordings to the Guardian ad Litem's office of my child speaking with any individual other than myself, unless I bring with me written authorization from the other parent/individual that I had permission to record the conversations as well as telephone numbers where the Guardian as Litem can contact the individual granting authorization to listen to the recordings. I understand that emails that I may give the Guardian ad Litem can also be problematic, in that the Guardian ad Litem will not review emails that have been obtained outside proper and legal channels. 18) I understand that the Guardian ad Litem has the right to file a Motion to Withdraw as Guardian ad Litem in my case and that he will do so if he feels that his involvement in the case is no longer proper pursuant to the Georgia Rules of Professional Conduct. 19) I understand that no one who speaks with the Guardian ad Litem should have an expectation of confidentiality. This includes my family, friends, neighbors, other witnesses, other professionals (including teachers), the child or children who are the subject of this action, the other party or me. Confidentiality is not inherent in the duties of the Guardian ad Litem as he is a fact-finder and an investigatory arm of the Court and he cannot keep secrets or confidences. I understand that I do not have to execute releases for the Guardian ad Litem to speak with my psychologist, psychiatrist, medical doctor, therapist, etc., but that if I do not execute a release, the Guardian ad Litem will formulate his own opinions about me without the assistance of my service providers. 20) I understand that the Guardian ad Litem is acting as an investigatory arm for the Court. He is not acting in any legal capacity for me. I release the Guardian from any and all liability for his reasonable and necessary actions arising out of the good faith exercise of his duties. 21) I understand that when the Court enters its final Order, the Guardian ad Litem's responsibilities are over. The Guardian ad Litem will only remain in the case after its conclusion if there is a specific Court Order directing him to remain involved. 22) I understand that it is imperative that I tell the Guardian ad Litem the truth as to any question he asks me on this form or in person, regardless of the setting or timing of the question posed. I understand that my failure to answer truthfully will damage my credibility with the Guardian ad Litem and will have a direct impact on the outcome of this case. 23) I understand that if I threaten the Guardian or harass him or his staff, he will seek whatever legal recourse available to him under the civil and criminal laws of this state and that my behavior will be reported to the Court.


I swear or affirm that I have read (or I have had someone else read to me) this form, that I understand its contents, and that I have discussed any concerns I have regarding this form with my attorney. The Guardian ad Litem has also satisfactorily answered any questions I have asked of him. I also swear or affirm that the information I have provided on this form is true, thorough, and correct to the best of my belief and knowledge. I further swear or affirm that I am not functioning under any mental disability as I complete this form and that I have not completed it while under the influence of alcohol or other drugs. Signature _______________________________ Sworn and subscribed to before me this ______ day of ____, _______. _____________________________________ NOTARY PUBLIC

information form of parent for guardian ad litem … information form for gal parents... · 707...

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