City, State, Zip 

 
Name 

 
Address 

 
Phone 

 
Email 

 

 
 
 
 
 
 
 
Check your email. You will receive information and 
documents at this email address.  

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

In the Matter of (select one) 
 

[  ]  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) 

Parent Coordinator Qualification 
Statement 

_______________________________ 
Case Number 

_______________________________ 
Judge 

____________________________________ 
(name of Petitioner) 

_______________________________ 
Commissioner 

and  

 

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

1. 

I have completed graduate level coursework in child development, and:   
(Choose at least one.) 

[  ]  I am a licensed clinical social worker in the state of Utah. 

[  ]  I hold a doctoral degree in psychology, and I am licensed as a psychologist 

in the state of Utah. 

[  ]  I am a physician in the state of Utah, and I am board certified in psychiatry. 

1224FAJ Approved August 17, 2018 / 
Revised May 1, 2022 

Parent Coordinator Qualification Statement 

Page 1 of 3 

 

[  ]  I am a licensed marriage and family therapist in the state of Utah. 

2. 

I have: (Choose one.) 

[  ]  at least 3 years of post-licensure clinical practice substantially focused on 

child therapy, marital therapy, or family therapy; and a working familiarity with 
child custody and parent-time law and the ethical issues involved in custody 
matters. 

[  ]  been appointed as a parent coordinator in fewer than 10 cases, and the court 

is located in an area of the state where there is a shortage of parent 
coordinator services. 

3. 

I agree to abide by all of the ethical and procedural requirements of a parent 
coordinator (Utah Code of Judicial Administration Rule 4-509). 

 declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

Sign here ► 

Typed or Printed Name 

 

 

 

 

 

 

Professional License Number 

 

License Type 

1224FAJ Approved August 17, 2018 / 
Revised May 1, 2022 

Parent Coordinator Qualification Statement 

Page 2 of 3 

  I

 

Date 

Certificate of Service 

I certify that I filed with the court and am serving a copy of this Parent Coordinator Qualification Statement 
on the following people. 

Person’s Name 

Service Method 

Service Address 

Service 
Date 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

 

 

 

 

 

 

 
Date 

Signature ► 

Printed Name 

 

 

1224FAJ Approved August 17, 2018 / 
Revised May 1, 2022 

Parent Coordinator Qualification Statement 

Page 3 of 3