online personal reference quest 9-14 · jeanie hackey kathryn kilian, ma, lpc personal reference...

Les Katz, PsyD, PC

Andrew Loizeaux, PsyD, PC

Toni Backman, PhD Felicia Greher, PhD Jeanie HackeyKathryn Kilian, MA, LPC

PERSONAL REFERENCE QUESTIONNAIRE

You are serving as a personal reference for

Your Name

The request is related to services currently being provided by Katz & Loizeaux Forensic Services, LLC. Our task is to gather information and make recommendations to the Court regarding the best interests of the child(ren). We are Court appointed, and are not working for either parent.

You are under no obligation to complete the enclosed questionnaire. We gather information from a variety of sources, and it is unlikely that any one source will determine the outcome. If you do decide to complete the questionnaire, nothing you write us can be kept confidential. A summary of what you write may be included in our report to the Court. Your questionnaire may also be requested and reviewed by the attorneys involved in the case. We may also be asked questions in Court regarding the information you have provided.

The information that you provide on the enclosed questionnaire will be greatly appreciated. We ask that you restrict your answers on the questionnaire only to areas within your own personal knowledge and observations, rather than what you have been told by others. Please remember to sign and date the questionnaire before you return it to us – please return within four weeks.

Thank you for your assistance in this matter.

Katz & Loizeaux Forensic Services, LLC

Please email your completed Questionnaire to [email protected] you are unable to submit the Personal Reference Questionnaire via email, you may mail a paper copy to:Katz & Loizeaux Forensic Services 1191 S. Parker Rd. Denver, CO 80231• Please do not fax• Please do not staple• Please try to limit your comments to the space given - if you want to make additional comments, please

attach additional pages to this document

of 10 Personal Reference Questionnaire 8/17 2017 Katz & Loizeaux Forensic Services, LLC

Please respond briefly to the following questions. Please restrict your answers to your own personal knowledge and observations rather than what you may have been told by others. We appreciate your thoughtful responses and your willingness to be of assistance. It is not necessary for you to know both parents in order to fill out this questionnaire. Simply answer questions pertaining to what you do know. If you do not have enough information to answer a question, simply state that, and go on to the next question.

Date Your Name

Address

City/State/Zip

Parents orGuardian

Child(ren)

How long have you known members of the family and what has your relationship been with each family member?

Les Katz, PsyD, PC

Andrew Loizeaux, PsyD, PC

Toni Backman, PhD Felicia Greher, PhD

Kathryn Kilian, MA, LPC Stacy Nolan, PsyD Dave Schutzman, MA, LPC


Describe your present relationship with each parent. How frequently do you see or speak with them?

Describe how well do you know the child(ren), and how frequent your contact with them is. What are your general perceptions and impressions of them? Describe any concerns you have about the child(ren).


Please describe each parent's involvement in the responsibilities of parenting during the marriage.

Mother (or guardian):

Father (or guardian):


Describe each parent's relationship with the child(ren) and the child(ren)'s response to each parent regarding:

How is affection demonstrated?




Discipline - what methods are used, are the methods appropriate for the situation, are the methods used effective?




What activities do the child(ren) and parent share?




How would you describe the quality of parenting by each parent - what do you think the strengths and limitations of each parent to be?




To your knowledge, does either parent have problems in ANY of the following areas?

Abuse of alcohol Mother Father Other (guardian)

Medical problems Mother Father Other (guardian)

Drugs/narcotics Mother Father Other (guardian)

Psychological problems Mother Father Other (guardian)

Criminal involvement Mother Father Other (guardian)

To your knowledge, does anyone else involved closely with the children have problems in ANY of the above areas?No Yes, please provide details:

Do you have any other specific concerns about either parent?

Is each parent's home environment safe and adequate for the child(ren)?

Please provide any additional comments that you believe would be important for the evaluators to consider.

Thank you for your comments. Please remember that we cannot keep any of your responses confidential. Occasionally, we find it helpful to call references and discuss further some of the answers to this questionnaire. We will do so only with your permission.

No Yes

Cell

I give permission for an evaluator from Katz & Loizeaux Forensic Services, LLC, to call me.

Best times to reach me by phone:

Home

Work Other

Email Address

I have reviewed this Personal Reference Questionnaire and have willingly completed. I understand that nothing I write or say to the evaluators is confidential and may be included in their final report. I understand that the parents and/or their attorneys may be allowed by Colorado law to review this questionnaire or any notes the evaluators have of conversations with me. Finally, I understand that the evaluators may be asked questions in Court regarding the information that I have provided.

Name Date

I Accept (if emailing form)By selecting the "I Accept" button, I am signing electronically - I agree my electronic signature is the legal equivalent of my manual signature on this form.

of 10Personal Reference Questionnaire 8/17 © 2017 Katz & Loizeaux Forensic Services, LLC

Signature

online personal reference quest 9-14 · jeanie hackey kathryn kilian, ma, lpc personal reference...

Documents