contact information

Name

City

State

Zip Code

Phone Number:

Alternate Phone:

Please answer all questions appropriate to your case.

CASE INFORMATION

Case Name:

1. Jurisdiction State:

2.Jurisdiction County:

3. Case Number:

4. Year documents 1st filed:

5. Case still in progress?

Yes No

FINANCIAL COST

6. Approximate sum of money paid related to case? (Include attorney fees, court filings, mediation, evaluations, supervised visitation, court ordered classes, therapy, etc.)

7. Have you ever had to file bankruptcy as a result of litigation costs?

Yes No

ATTORNEY HISTORY

8. Have you ever been represented by an attorney in this case?

Yes No

9.If so, how many attorneys represented you in this case?

10. Has your ex-spouse/partner ever had legal representation when you did not?

Yes No

CHILDREN

11. What were the ages of the children of this relationship at the time of the separation?

Girl's ages:
Boy's ages:

12. What is the approximate percentage of time each caretaker spent caring for the children before the separation?

Mother: %
Father:%
Relative: %
Other: %

13. At the time of separation, did the primary caretaker maintain primary physical custody?

Yes No

PRIMARY ISSUES

14. Over which of the following issues were there disputes in your court case? (mark all that apply)

Property settlement
Spousal support
Child support
Move away
Child custody/visitation
Alcoholism
Drug abuse/type of drugs:
Other:

15. Who initiated the litigation?

Mother Father

16. Were you the victim of domestic violence perpetrated upon you by the other parent?

Yes No

17. If so, did your children witness the violence?

Yes No

18. Did the violence begin or escalate after separation?

Yes No

19. Did your ex-spouse/partner ever threaten to take the children if you left the relationship?

Yes No

20. Were there allegations of child abuse made during your family court litigation?

Yes No

ABUSE ALLEGATIONS

21. Physical abuse allegation?

Yes No

Identified as perpetrator:

Father Mother Other

First allegated by:

Child Father Mother Other

22. Sexual abuse allegation?

Yes No

Identified as perpetrator:

Father Mother Other

First allegated by:

Child Father Mother Other

23. Verbal/emotional abuse allegation?

Yes No

Identified as perpetrator:

Father Mother Other

First allegated by:

Child Father Mother Other

24. Neglect allegation?

Yes No

Identified as perpetrator:

Father Mother Other

First allegated by:

Child Father Mother Other

25. Other allegation?

Yes No

Identified as perpetrator:

Father Mother Other

First allegated by:

Child Father Mother Other

26. What was the age and gender of the first child at the onset of his/her abuse?

Boy Girl

27. What was the age and gender of the second child at the onset of his/her abuse?

Boy Girl

28. Did the child positively identify the other parent as the perpetrator?

Yes No

29. Was there medical/physical evidence of the abuse?

Yes No

30. Was there other corroborative evidence of the abuse?

Yes No

31. What were the children's symptoms? (check all that apply)

Sexual acting out
Depression
Stomach/head/other pain
Dissociation
Overwhelming anger/rage
Nightmares/insomnia/sleep disorders
Fears/phobias:
Eating disorders
Regression (bedwetting/leak feces/thumb sucking)
Constipation/diarrhea
Learning disability
Attention deficit
Suicide attempt
Other:

32. Did the children receive Victim of Crime funding for therapy related to the crime?

Yes No

EX-SPOUSE/PARTNER HISTORY

33. Prior to the separation, did your ex-spouse/partner receive any of the following labels by mental health professionals? (mark all that apply)

Schizophrenia
Bi-polar disorder
Borderline personality
Depression
Anxiety
Post Traumatic Stress Disorder
Other:

34. Does s/he have a history of alcohol and/or drug use?

Yes No

35. If so, is s/he clean and sober?

Yes No

36. Length of time clean and sober:

37. Does s/he have a criminal history?

Yes No

38. If so, what was s/he Arrested for?:

39. Convicted of?:

PROTECTIVE PARENT HISTORY

40. Prior to the separation, did you receive any of the following labels by mental health professionals? (mark all that apply)

Schizophrenia
Bi-polar disorder
Borderline personality
Depression
Anxiety
Post Traumatic Stress Disorder
Other:

41. Do you have a history of alcohol and/or drug use?

Yes No

42. If so, are you clean and sober?

Yes No

43. Length of time clean and sober:

44. Do you have a criminal history?

Yes No

45. If so, what were you arrested for?

46. Convicted of?:

ADVISE

47. Did anyone ever advise or insist that you not mention domestic violence or child abuse in family law court?

Yes No

48. If so, who advised you?

Attorney
Mediator
Advocate
Court personnel
Other:

49. Did your attorney ever tell you that pursuing court action against your ex-spouse/partner could negatively affect your case?

Yes No

CHILD CUSTODY

50. Was custody changed to the other parent over your objection, by an emergency court order, or without your court presence?

Yes No

CHILD CUSTODY

51. Was unsupervised contact given to the identified offender despite evidence of violence or abuse?

Yes No

52. Was unsupervised contact given to the identified alcoholic/drug abuser without drug testing?

Yes No N/A

53. Was custody changed after you raised any of the following issues? (mark all that apply)

Violence
Child abuse
Substance abuse
Criminal conduct
Violations of court order
Move-away
Spousal support
Child support

54. Were judicial findings made stating that you were a danger to your children or that you were an unfit parent?

Yes No

55. Were you ever placed on supervised visitation?

Yes No

56. If so, length of time:

57. Were you restricted from having any contact with your children?

Yes No

58. If so, length of time:

59. Do you believe the other parent attempted to gain increased custody to avoid paying child support?

Yes No

60. Was financial discovery conducted in your case?

Yes No

61. Did you give up assets to keep custody?

Yes No

COURT MEDIATION

62. Did you participate in court-connected mediation regarding custody?

Yes No

63. If so, was mediation:

Voluntary
Court ordered
Coerced by threats

64. Were you required to meet face-to-face with an ex-spouse/partner who perpetrated violence and/or threats of harm?

Yes No

65. Did you lose any custody rights or contact with your children as a result of recommendations by a mediator?

Yes No

EVALUATIONS

66. Did you participate in court connected evaluations regarding custody?

Yes No

67. If so, who was evaluated?

Mother
Father
children
Other:

68. Who selected the evaluator?

Mother
Father
children
Other:

69. Who paid for the evaluator?

Mother
Father
children
Other:

70. Total amount paid for custody evaluation:

71. Did you lose any custody rights or contact with your children as a result of recommendations by the evaluator?

Yes No

CHILD'S ATTORNEY

72. Did your children have an attorney/guardian?

Yes No

73. If so, was he/she court appointed?

Yes No

74. Who selected the children's attorney?

Mother
Father
Court
Other:

75. Who paid for the children's attorney?

Mother
Father
Court
Other:

76. Total amount paid for child attorney:

77. Did this attorney aggressively advocate for the safety of your children?

Yes No

SYSTEM SUPPORT

78. Was the other parent ever for spousal or child abuse?

Arrested and/or
Prosecuted

Yes No

79. Was Child Protective Services ever contacted to intervene in your case?

Yes No

80. If so, did they protect your child?

Yes No

EVIDENCE

81. Did any court related professional ignore, minimize, or refute evidence of abuse in your case?

Yes No

82. If so, who?

Mediator
Evaluator
Attorney for minor
Judge
Other:

83. Did any court related professional label you with any of the following?

Parent Alienation Syndrome
Alienator
Folie a duex
Munchhausen's Syndrome by Proxy
Delusional
Schizophrenia
Bi-polar disorder
Borderline personality
Depression
Anxiety
Post traumatic stress disorder
Other:

84. In your case, was Richard Gardener, MD.

An expert witness
A consultant
Quoted
Other:

PROCESS

85. Do you believe you were discriminated against for your attempts to protect yourself and/or your children?

Yes No

86. If so, do you believe this occurred due to:

Unethics among court-related professionals
Unethics between ex-spouse/partner & court-related professionals
Financial/social status of your ex-spouse/partner
Gender bias
Other:

87. Were evaluator or mediator recommendations ever provided to the court less than 10 days before a hearing?

Yes No

88. Were you prevented from seeing evaluations or reports that resulted in custody decisions?

Yes No

89. Were you ever denied the ability to adequately present your case (unable to present/examine witnesses, etc.)?

Yes No

90. Were hearings resulting in custody decisions held without your knowledge or ability to be present (ex parte)?

Yes No

91. Were hearings regarding custody and visitation ever conducted without a court reporter present?

Yes No

92. Were you ever threatened that talking publicly could result in damage to your case?

Yes No

93. Were court transcripts complete and accurate?

Yes No

94. Were court transcripts denied or delayed?

Yes No

95. If so, how long were the transcripts denied?

96. Have you ever been incarcerated in a jail or mental health facility due to the family law case?

Yes No

CURRENT CUSTODY ARRANGEMENT

97. What best describes your children's current custody arrangement? (mark all that apply)

Primary with protective parent, supervised with perpetrator
Primary with protective parent, UNsupervised with perpetrator
Joint custody
Full custody with perpetrator parent
Supervised visitation with protective parent
No contact with protective parent
Other:

98. Are you able to protect your children?

Yes No

99. Do you believe your children are still being abused?

Yes No

100. Did your children continue to report abuse after custody was changed to the identified abuser?

Yes No

101. Did you stop reporting suspected child abuse for fear your contact

Yes No

Do you give us permission to contact you for further information?

Yes No

You may use the space below for comments or questions:

Thank you for contributing to this survey.

Please print and mail this survey to:

WADVI INC C4628893, 44 Visitacion Avenue, Brisbane, California 94005, United States

Or submit it electronically by clicking the "send Request" button below. (Confidentiality respected, but not guaranteed, due to Internet security.)

Wadvi Survey

protective parent survey questionnaire

contact information

CASE INFORMATION

FINANCIAL COST

ATTORNEY HISTORY

CHILDREN

PRIMARY ISSUES

ABUSE ALLEGATIONS

EX-SPOUSE/PARTNER HISTORY

PROTECTIVE PARENT HISTORY

ADVISE

CHILD CUSTODY

CHILD CUSTODY

COURT MEDIATION

EVALUATIONS

CHILD'S ATTORNEY

SYSTEM SUPPORT

EVIDENCE

PROCESS

CURRENT CUSTODY ARRANGEMENT

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