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KING COUNTY SUPERIOR COURT

FAMILY COURT SERVICES

REFERENCE QUESTIONNAIRE

Name and Phone Number of parent/guardian for whom you are completing the questionnaire:

          Respondent/Father                                                                                      

                    Name                                                                     Phone

                                                                                                                                    

                    Social Worker                                                        Phone

                                                                                            200020842                         

        Superior Court Cause No                                      Family Court Services No.

                    IN RE:                                                                                                                                      

INSTRUCTIONS

As you answer each question below, please keep in mind that it is the responsibility of the Court to safeguard the welfare and future development of the child(ren) in this family. You can help the Court in meeting this responsibility by being objective. The evaluator may contact you to discuss your statement with you. This questionnaire is to be completed immediately and returned to: Regional Justice Center, Family Court Services, 401 North Fourth Avenue, Suite 1D, Kent, WA. 98032.

Your Name                                  Father's Friend/Employer                                                  

Your address                                      

            Street                                                     City                  Zip

Your phone _  ___         ___

Home                                                                                Work

 

Your relationship to the parent/guardian above (friend, relative, mother, father, employer, etc.) _former employer___

How long have you known this parent/guardian?                             10 years                   

How often do you see him/her:                              Date last seen      9/98  

How long have you known the child(ren) in this case: 4.5 years about   (since birth) to present

How often do you see them:                0                   Date last seen       9/98 

Do you know the other parent?   Yes                            no                    

If yes, for how long:       approx. 6 years                  Date last seen       9/98    

1

A) PHYSICAL ENVIRONMENT:

If you have been in the home of the parent/guardian for whom you are a reference, describe

the home including housekeeping standards, who prepares meals, etc.:  

Both parents prepare meals, bathe child, change and feed their son. The house is in a orderly clean manner. Child  is loved, clean, and well cared for. Both parents communicate in sign language w/ their son.

 

B) CARE OF CHILD(REN):

Describe how this parent/guardian treats the child(ren) (cleanliness, clothing, discipline, supervision):

is well supervised and disciplined well. I have never seen any type of abuse by either parent towards or

 

Describe the quality of the relationship between the parent/guardian and the child(ren):

Loving, for this child will thrive well w/ both parents in his life. They both love him very much.

 

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