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* 1. First and last name

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* 2. Judge for your case

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* 3. Name of other parent who will attend the class

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* 4. If you were in a relationship with the other parent, how long?

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* 5. Number of children?

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* 6. Ages of children

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* 7. List any other ages for children

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* 8. My biggest concern(s) about my child/children during this time is:

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* 9. Are the children aware of the divorce?

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* 10. Is there a history of domestic violence with the other parent who will attend a class that we should be aware?

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* 11. How do you feel about attending the class with the other parent?

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