Center for Parental Responsibility

Brief Preliminary Initial PHONE Intake FORM

(Print form, complete, and mail back to CPR�� PO Box 130776�� Roseville MN 55113)


YOUR Name:������������������������������������������������������������� ������������ Date of FIRST PHONE Intake: __________________

����������������������������������������������������������������������������������������������� Time/Length of Phone Intake: ___________________

Are you:�� ������ married����� divorced���� divorce in process��� parent out of wedlock���� other


Are you: �������� custodial parent���� non-custodial parent��� grandparent�� ����significant other/friend/second spouse�� ����other �����don�t know


Full Mailing Address: (street, city, state, zip) � this is used to link people to legislative areas



Phone:Home __________________________________������������� Cell _________________________________

����������� (INCLUDE area code -- we prefer to not call people at work � we call people to remind them of meetings)


Email: ____________________________________________�� How did you hear about CPR: ____________________

����������� (our most frequent type of communication is through email, if email is not available, its difficult to get/stay connected)


Alternative Name/Phone: ________________________________________________________

(if you change numbers or move, who might be able to help us locate you to be sure you stay in the loop)


What best describes where you are at:���������

q No COURT order - in process of divorce or paternity issues � there has never been a court order to establish custody, visitation (parenting time) or child support.

q COURT order - a court order has previously been established ... order is either fine as written or it needs to be modified because the court order not being followed or must be changed .... q Temporary Order ONLY�� q OFP order in place


What are the basics of the court order:

What county is your order/hearings in? _______________________________________________________________

Who has sole/joint legal custody? ___________________________________________________________________

Who has sole/joint physical custody? ________________________________________________________________

What is the court ordered parenting time schedule? _____________________________________________________


How far do you live from your children? why the distance?_______________________________________________

Was your child support based on your true and accurate income or phantom imputed income? ___________________

Have you ever tried to modify your child support? If so, what happened? ____________________________________


What issues are most concerning to you: (check all those that apply, rank in order of importance if possible)

q Custody: legal custody (medical, school, etc) issues ��������������������������������������� q Order for Protection: need to fight

q Custody: physical custody --- problems or battling who gets custody���������������� q Need an attorney referral

q Visitation/parenting time problems (not getting to see your children) ���������������� q Pro Se papers/guidance

q Help for child support payment problems or arrears problems�������������������������� q Other:

q Help for child support enforcement issues: drivers license suspensions, contempt, etc

q Have a scheduled hearing coming up for which urgent support or information is needed


Please briefly explain your story: (Intake volunteer is not trained to hear your entire story at this time, but if you can give us a brief description of your biggest issue we can try forward your case to the right person to help provide you the best guidance at this time)�����������������������������������

USE REVERSE SIDE FOR MORE SPACE .....DESCRIBE MAIN PROBLEM ..and any important background information



What is your specific need today: (What were you hoping to find through CPR. If we could do 1-3 things to assist you, what would it be?)




Any special note/observation/suggestion from INTAKE volunteer?