Screening Form

Service *
Which Hannah's House service are you signing up for?
Leave blank if unknown
Name *
Name
Please provide name on the Court Orders
Custodial or Non-Custodial? *
Are you the Custodial OR Non-Custodial Parent?
Mailing Address *
Mailing Address
Phone Number *
Phone Number
Alternative Phone Number
Alternative Phone Number
Other Party's Name
Other Party's Name
Other Party's Mailing Address
Other Party's Mailing Address
Other Party's Phone Number
Other Party's Phone Number
If so, when?
Indicate NA if not Applicable
FCS Mediator OR Private Mediator's Phone Number
FCS Mediator OR Private Mediator's Phone Number
Please provide their name, address, phone number and email if available.
Please provide the attorney's name, address, phone number and email if available.
If yes, please provide name, address, phone number and email if available. Indicate "NA" if Not Applicable.
If so, indicate who's therapist it is, their name, address, phone number and email if available. Indicate "NA" if Not Applicable
Please provide the ALL children's full name (as they appear in court order documentation), their dates of birth and the sex of each child.
Provide their name, phone number and email if available. Indicate "NA" if Not Applicable.
For example: Due to a Restraining Order, due to child abuse, mental illness, etc.
If yes, where did you receive services and the dates of services:
Next Court Date?
Next Court Date?
Next Mediation Date?
Next Mediation Date?
Is there any risk of flight/abduction on the part of either parent? *
Are there any Restraining Orders in effect? *
Is there a history or current concern about Domestic Violence? *
If there a history or current concern about Child Abuse (physical or sexual)? *
Is there a history or current concern about Alcohol or Drug Abuse? *
Is there an order for alcohol or drug assessment/testing? *
Do you smoke cigarettes around the child(ren)? *
Indicate "NA" if no legal issues pending.
Indicate "NA" if Not Applicable
Have you heard about out Transitions Family Program (psycho-educational & clinical services)? *
I understand I will receive acknowledgement of receipt of this screening form within 48 hours and I will then be scheduled for a required new-client orientation. I also understand Hannah's House will start working on contacting the other party to also get them started on the intake process, if they have not already done so. *
Orientation is a flat rate of $60 for a class orientation. Please come prepared by bringing copies of the following (if applicable to my case): Family Court Services (FCS) Report; Court Order; Restraining Orders; DV Filings; Proof of income (required if paying for services); Payment for orientation (NO personal checks); Valid ID. Should you need to cancel a scheduled orientation please inform Hannah's House. If you simply do not show up, you will incur a $60 no-show fee.