Questions about Children -

Option 1 - Complete the form now.

Fill in the fields in the form and use the button at the end to submit to Pinder Rehabilitation Services.

Option 2 - Complete the form later.

Enter your name, phone, and email in at the top of the form and use the submit button in the red border.

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Completed by details

Name:*

Email:*

Phone:

to above email address.

Email form for completion.

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Children details

Child 1.

Child's Name

Age

Date of birth

Grade

School Name

Hours

Child 2.

Child's Name (2)

Age (2)

Date of birth (2)

Grade (2)

School Name (2)

Hours (2)

Child 3.

Child's Name (3)

Age (3)

Date of birth (3)

Grade (3)

School Name (3):

Hours (3):

Child 4

Child's Name (4)

Age (4)

Date of birth (4)

Grade (4):

School Name (4):

Hours (4):

General Items

After School Activities:

Who transports? If you cannot who does?

Any special learning problems with the children?

Any special emotional or physical challenges?

Any situational challenges because of the divorce?

Do you have a support system, such as family in the area, friends, church?

Do you have any other responsibilities, such as elderly parents that you care for?

What does your spouse contribute? Transportation?

Are there any temporary custody arrangements?

Is you spouse reliable (picks up kids when he says he will, etc) Any patterns?

Other Comments: