Please return form in the self-addressed envelope provided, or to: 
450 So. State; P.O. Box 140241;  Salt Lake City, Utah 84114-0241 
You may also email it or fax it to: 
Fax (801) 578-3843, Email cpm@utcourts.gov 
 

CO-PARENTING SCREENING INTAKE FORM 
 

 

 

 

 

. 

IDENTIFYING INFORMATION C (personal information will be kept confidential) 

ULL NAME:_____________________________________________________________________ 

FIRST 

MIDDLE 

LAST 

OME ADDRESS:__________________________________________________________________ 

STREET ADDRESS OR  P.O BOX 

 

 

APT. # 

_____________________________________________________________________________ 

City 

 

State 

ZIP 

 

 

 

 

ome Phone: _____________________Work Phone: ______________________Cell: ______________________ 

MAIL ADDRESS;_____________________________________________________________________________ 

ttorney’s Name:_______________________________________________________________________________ 

ONTACT PERSON:___________________________________________________________________________ 

 

 

Name 

 

 

Phone Number 

___________________________________________________________________________________________________________________ 

City 

State 

 

ZIP 

 

 

 

Address 
 

 
 
II.  CHILDREN (Involved in this Action) 
 

 
 
Name 
_________________________________  

 
 

 

 

 

 

Date of Birth 
___________________________ 

_________________________________  

___________________________ 

_________________________________  

___________________________ 

 

 

 

 

III.  DEMOGRAPHIC INFORMATION   

Race/Ethnicity (Please Check Only One)  

Approximate Annual Income 

 

 American Indian or Alaskan Native 

 

(cid:0) Asian American 
 
(cid:0) Black/African American   
 
(cid:0) Hispanic or Latino 
(cid:0) Native Hawaiian or Other Pacific Islander 
(cid:0) White 
(cid:0) Two or More Races 

 
 
 

 

(cid:0) Less Than $10,000 
(cid:0) $10,000 - $19,000 
(cid:0) $20,000 - $29,000 
(cid:0) $30,000 - $39,000 
(cid:0) $40,000 And Above 

  I

  F

 

  H

 

  _

 

    H

  E

  A

  C

 

  _

   

 

 
 
 
 
 
 
 

                                                                                                                                           Please complete entire form (turn over) 

 

 

 

 

 

 

 

 

 

 

 

 

 

  (cid:0)

       

 

 

 

 

 
 
 
 

 

 

 

 

 

V.  PARENT-TIME (VISITATION) 

S THERE A CURRENT ORDER REGARDING PARENT TIME? 

YES  

   NO 

 

(IF YES): 

1)  ARE THE TERMS OF YOUR CUSTODY/PARENT-TIME ORDER CLEAR? 

YES    

    NO 

2)  ARE THE TERMS OF YOUR CUSTODY/PARENT-TIME ORDER BEING MET? 

YES 

   NO  

IF NOT, WHAT IS YOUR COMPLAINT?__________________________________________ 

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________ 

FOR NON-CUSTODIAL PARENTS ONLY: 
IN THE PAST 30 DAYS: 
1. 

HOW MANY DAYS WERE YOU SUPPOSED TO SEE YOUR CHILD(REN)?__________________________ 

HOW MANY DAYS DID YOU ACTUALLY SEE YOUR CHILD(REN)______________________________ 

IN YOUR OPINION, WHAT NEEDS TO BE DONE TO RESOLVE THIS PROBLEM?_________________________ 

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________ 

HAS THERE BEEN DOMESTIC VIOLENCE WITH THE OTHER PARENT (CO-PARENT)? 
 
IF YES, PLEASE EXPLAIN:_________________________________________________________________ 

YES 

 

  NO 

_______________________________________________________

_______________________________________________________

__________________________________ 

IS THERE A CURRENT ACTION REGARDING CHILD SUPPORT? (CIRCLE ONE) 

YES 

   NO 

IF YES, WHEN WAS THE ACTION FILED?_______________________________________ 

IS THERE A CURRENT PROTECTIVE ORDER? (CIRCLE ONE) 

 

 

YES 

   NO 

  I

 

 

2. 

 

  I