TABLE OF CONTENTS  
CHILD CUSTODY EVALUATION∗ 

ase No. ________________________ 

udge ___________________________ 

ommissioner ____________________  

 

  C

  J

  C

 
IN THE __________ JUDICIAL DISTRICT COURT 
_______________________ COUNTY, STATE OF UTAH  

This is a private record. 

[  ]  the Marriage of (for a divorce with or without 
children, annulment, separate maintenance, or 
temporary separation case) 
[  ]  the Children of (to establish custody, 
parent-time or child support) 
[  ]  the Parentage of the Children of (for a 
paternity case) 

____________________________________ 
(name of Petitioner) 

n the Matter of (select one) 

  I

 

and  

____________________________________ 
(name of Respondent) 
____________________________________________ 
Other parties (if any) 

PPOINTED CUSTODY EVALUATOR:  _______________________________ 

ATE OF SETTLEMENT CONFERENCE:  ______________________________ 

ATE REPORT PERFORMED:  _______________________________________ 

INOR CHILD(REN) & DATE(S) OF BIRTH:  ___________________________ 
___________________________________________________________________ 

OTHER: _________________________________________________________ 

ATHER: __________________________________________________________ 

THER PARTIES EVALUATED AND RELATIONSHIP TO CHILDREN: 

(e.g., stepparent, parent's partner) 

__________________________________________________________________ 

UARDIAN ad LITEM: ______________________________________________ 

OTHER'S COUNSEL: ______________________________________________ 

ATHER'S COUNSEL: _______________________________________________ 

                                                 
∗ These forms and procedures have been approved by the Judicial Council, and the Supreme Court.  Any custody 
evaluation submitted to the court must conform in substance to these forms.   
 

1 

  A

  D

  D

  M

  M

  F

  O

 

    _

  G

  M

  F

 

ONCLUSIONS:                                                                                   Page and paragraph 

.   Summary of Children's Needs: 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

.   Summary of Each Parent's and Stepparent's Ability and Propensity to Provide for    these 

Children's Needs: (Include parenting skills, impairments, availability, willingness to facilitate 
child's relationship with other parent, and the unique 
 manner in which each parent's skills fit the children's needs.) . . . . . . . .  

.  Suggested Custody Arrangements (Legal and Physical): . . . . . . . . . . . . .  

  
D.  Suggested Parent-Time Arrangements: 

 . . . . . . . . . . . . . . . . . . . . . . . . .  

(State if standard; provide page numbers if non-standard) 

.  Rule 4-903 Considerations: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

(place all of these together in report and indicate page numbers ) 

.  Special Considerations:  

ACKGROUND: 

.  Mediation or Resolution Attempted?   

 

   Yes   

No  

.  Temporary Custody and Parent-Time Arrangement: 

 state briefly 

.  Current Living Arrangement:  (who else lives in each home?)    . . . . . .    

(state briefly or provide page and paragraph numbers)  

.  Each Parent's Perception of Custody Issues   . . . . . . . . . . . . . . . . . . . . . . 

VALUATOR'S PROCEDURES: 

A.  Interviews of Adults and Children:  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
B.  Home Visits and Other Observation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
C.  Psychological Testing:  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   
D.  Collateral Contacts:  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

2 

    C

  A

    B

  C

          E

  F

          B

  A

  B

      C

  D

  E

 

E.  Documents and Other Material Reviewed:    . . . . . . . . . . . . . . . . . . . . . . . . 
 

 

3