COUNTY SUPERIOR COURT
and Phone Number of parent/guardian for whom you are completing the
Superior Court Cause No
Family Court Services No.
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,
relationship to the parent/guardian above (friend, relative, mother,
father, employer, etc.)____Friend___________
long have you known this parent/guardian? 15
often do you see him/her: 10
x's year Date
last seen December
long have you known the child(ren) in this case:
often do you see them: 5-6
times year Date
last seen September
you know the other parent? Yes
If yes, for how long: 4 years Date last seen September 21 2000
you have been in the home of the parent/guardian for whom you are a
home including housekeeping standards, who prepares meals, etc.:
The house is clean, and tidy. Both prepare meals for . Dishes are always done, Floor is clean.
CARE OF CHILD(REN):
how this parent/guardian treats the child(ren) (cleanliness, clothing,
Father/Respondent has always been good with . is always clean, and well behaved. Father/Respondent is looking after with his best interests in mind. Any discipline I have seen is normal. If did something wrong, the usual discipline that I have observed was a time out. I have never seen the Father/respondent harm . He is very caring towards his son.
the quality of the relationship between the parent/guardian and the
In my opinion, the Father/Respondent has a good relationship with . When they discovered could not hear, the father respondent went to sign language classes so he could communicate with his son. seems happy when he has been at our house with the father/respondent.
you ever witnessed physical or emotional abuse of the child(ren) by
either parent/guardian (explain and give details):
I have never seen either parent be abusive towards .
each child, his/her behavior and include any physical or emotional
problems known to you:
is well behaved, and polite child. He appears to be happy, and care free as a child should be.
your knowledge, does either parent/guardian have problems in any of the
ABUSE OF ALCOHOL: Yes No √
the answer to any of the above is YES, please give details:
kind of residential plan do you think would best provide for the
A plan that allows both parents quality time with . Any child deserves the right to have both parents in his/her life. With being unable to hear, I think it is more important he has the support of both parents.
you feel that either parent is unfit to have residential time with the
YES, explain why:
I have known the father/respondent for 15 years, and have never seen him become physically violent with another person. He is good with , and loves him very much. Everything the father/respondent does is for benefit. He is continuing with his education so he can provide a better life for his son.
I certify that the above information is true and correct to the
best of my knowledge. I
understand that by law, "The evaluator/investigator shall make
available to counsel and to any party not represented by counsel
…….” (1) the evaluator/investigator's file; (2) texts of
diagnostic reports; (3) names and addresses of persons consulted and (4)
investigators and any person whom (s)he
has consulted may be called for cross-examination.
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