Intake Form

This intake questionnaire is designed to familiarize your provider with your case, needs, and concerns. Please be prepared to upload any relevant documentation, court orders, and formal photo identification. Please contact our office at info@throughthevale.com or (916) 360 - 0364 with any questions or concerns.

Service(s) Requested (mark all that apply)

How did you hear about us?

Personal Information

I am the...

Petitioner

Respondent

Other

First name

Last name

I am an employee, case worker, or other representative of a formal agency or organization, such as DCFS or CPS (also known as a "referring agency"), and am responsible for scheduling & coordinating on a client's behalf.

Email

Phone

Residential address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Party Information

Is there a no-contact order of any kind in place?

Yes

No

Unknown

Petitioner's full name

Phone Number (if known)

Petitioner's attorney

Attorney's email

Petitioner's relationship to the children

Mother

Father

Other

Respondent's full name

Phone Number (if known)

Respondent's attorney

Attorney's email

Respondent's relationship to the children

Mother

Father

Other

Minor Child(ren)'s Information

Number of children included in the order

Child's full name

Date of birth

Court Information

Case Number

Judge or Mediator

County

Date of last hearing

History

Estimate the number of times law enforcement has been called to enforce or assist with a no-contact order

Estimate the number of times law enforcement has been called to enforce or assist with a scheduled exchange or visitation

Is there a history of abuse towards the child(ren) by any other party in this order?

Yes

No

Unknown

Where did the last visitation or exchange take place?

Was the last visitation or exchange professionally supervised?

Yes

No

Unknown

When did the last visitation or exchange take place?

Additional information or concerns

Identification Information:

I do not have a vehicle

Vehicle Make & Model

Year

Lic. Plate Number

Primary Color

Personal identification

Identification number

Identification

Court Order

Additional Supporting Documents (if any)