Government of Ontario: Ministry of the Attorney General

Office of the Children’s Lawyer
c/o MGS Mail Delivery Services
2B-88 Macdonald Block
77 Wellesley Street West
Toronto ON M7A 1N3
Telephone: 416 314-8000
Facsimile: 416 314-8050

Intake Form – Instructions

Custody/Access Cases under the Divorce Act and/or the Children’s Law Reform Act

Please read this page before you fill out the form

Please fill out this form only if a Judge has made a Court Order requesting the involvement of The Children’s Lawyer. Please send the completed form to us, dated and signed, within 14 days of the date of the Court Order. You can mail or fax it to us. Our address and fax number are on the top, left-hand side of this page. If your Intake Form is not sent to us within 14 days we will close our file.
If you have a lawyer, he or she should help you complete this Intake Form. There are places in the Intake Form where we ask for your signature. Please make sure that you, not your lawyer, sign these sections. If you do not have a lawyer, please fill out the form to the best of your ability.
We will let your lawyer (or you, if self-represented) know if we accept or reject the case. If we decide to get involved, we may assign a lawyer, a clinical investigator or both, to represent the children.
The following tips will help us review your Intake Form:
- Please try to set out your concerns in the space provided. Please do not provide affidavits or other court pleadings with your Intake Form.
- If you want to have services provided in French, please make sure that you check off the box in Section III.
- On the last page of this form there is a checklist of the documents we need to review your case. Please send in only these documents with your Intake Form.
- If your answers are handwritten, please use black or blue ink and print clearly so that we can read the information you provide. Please give specific dates when we request them. It helps us understand the history of the file.
- The Intake Form has 14 sections, please make sure that all sections are included. There are 3 sections in the Intake Form that need your signature (Section II, Section X and Section XIV). Please make sure that these sections are signed by you, not your lawyer.

The information in this form is subject to the Ontario Government’s Freedom of Information and Protection of Privacy Act. The Children’s Lawyer will use the information to decide whether or not to become involved in your case. The information will also be used to help us provide professional services for the child(ren). Therefore, the information you provide in this form is not confidential. Please note, however, that The Children’s Lawyer will not provide the other party with a copy of this form unless ordered to do so. If you have any questions about this issue, you can contact Elizabeth Keshen, Counsel at the Office of the Children’s Lawyer. Ms. Keshen’s phone number is 416 314-8089.

Section I Information Regarding Other Services

1. Has The Children Lawyer ever been involved with you, the
other party and/or the child(ren) before?

Yes No If yes, in what year(s)?
What was the name of the lawyer and/or clinical investigator involved with your case?

2. Is there an assessment in progress or has an assessment
been completed dealing with parenting issues and/or
custody/access to the child(ren)?

Yes, ongoing Yes, completed No

If yes completed, When (yyyy/mm/dd)

By whom (last, first name)

If assessment is completed, please attach a copy.

3. Have you or the other party ever attempted mediation?

Yes No

If yes, When (yyyy/mm/dd)

What was the name of the mediator? (last, first name)

Section II Jurisdiction

Where is the Court hearing your case located? (city/town/region)

The Children’s Lawyer requires that you and the children go to interviews and other meetings in the same region as the Court that is dealing with your custody and/or access matter. In order to consider your Intake Form we need you to agree to go to those interviews and/or meetings in the region by signing below.

Signature

Date (yyyy/mm/dd)

Section III Information About Yourself

Last Name

First Name

Middle Initial

Date of Birth (yyyy/mm/dd)

Place of Birth

City/Town

Province

Country

Address

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code)

Home

Work ext.

Cell

Are you employed?

Yes No

If yes, What kind of work do you do?

May we telephone you at work?

Yes No

Your Lawyer’s Name (last, first name)

Name of Firm

Address

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code) ext.

Fax No. (include area code)

Language

Do you speak English?

Yes No

Do you speak French?

Yes No

If neither (english or french), what language(s) do you speak?

Do you request that services be provided to you in French?

Yes No

Does/do your child(ren) speak English?

Yes No

Does/do your child(ren) speak French?

Yes No

If neither (english or french), what language(s) does/do the child(ren) speak?

Do you request that services be provided in French for your
child(ren)?

Yes No

Please note that The Children’s Lawyer provides services in English and French only. The Children’s Lawyer is unable to provide interpreters for anyone other than the child(ren). If you require an interpreter to communicate with the lawyer/clinical investigator assigned by us to the case, you will need to provide the interpreter yourself. The Children’s Lawyer will pay for the cost of an interpreter to speak with the child(ren).

Section IV Information About The Other Party

Name (last, first name)

Previous Name (if any) (last, first name)

Date of Birth (yyyy/mm/dd)

Place of Birth

City/Town

Province

Country

Address

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code)

Home

Work ext.

Cell

Lawyer’s Name (last, first name)

Name of Firm

Address

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code) ext.

Fax No. (include area code)

Language

Does the other party speak English?

Yes No

Does the other party speak French?

Yes No

If neither (english or french), what language(s) does he/she speak?

Section V Some General Questions

1. What is your relationship to the child(ren)?

Parent Father Mother
Other, please specify

2. What was your relationship to the other party in
this proceeding?

Married
Lived together but not married
Never lived together
Other, please specify

3. When did you first begin your relationship? (yyyy/mm/dd)

4. If you were married or lived together, what is the date of separation? (yyyy/mm/dd)

5. What is your current relationship to the other party in
this proceeding?

Divorced
Separated
Never lived together
Other, please specify

6. Currently, are you and the other party living in the
same house?

Yes No

7. Who currently lives with you and what is their
relationship to you?

1. Full Name

Relationship

2. Full Name

Relationship

3. Full Name

Relationship

Section VI Information About The Legal Proceedings
(To be completed with the assistance of your lawyer,
or by you if self-represented)

1. I am asking the court to make the following orders:

sole custody of the child(ren)
joint and/or shared custody of the child(ren)
access to the child(ren) please specify

restraining order
contempt order
child support
termination of support arrears
exclusive possession of matrimonial home
an assessment under s.30 of the Children’s Law Reform Act
mediation under s.31 of the Children’s Law Reform Act

supervised access to Applicant Respondent

no access to Applicant Respondent

non-removal order
spousal support
variation of child support
division of property
Other, please specify

2. When is the next court appearance? (yyyy/mm/dd)

3. What is the nature of the next court appearance?

case conference
settlement conference
motion
trial management conference
trial

Section VII Information About The Children
(If there are more than two children, please attach
additional pages)

Child #1

Last Name

First Name

Middle Initial

Gender

Male Female

Date of Birth (yyyy/mm/dd)

Name of Daycare/School

Grade

Address of Daycare/School

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code)

Name of Daycare Provider/Teacher (last, first name)

Does the child have any special health/education needs?

Yes No
If yes, what are they?

Provide the following information about any health/educational professionals who are involved with this child (for example, doctor, counsellor, psychologist, psychiatrist).

Professional #1

Type of Professional

Name (last, first name)

Address

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code) ext.

Fax No. (include area code)

Professional #2

Type of Professional

Name (last, first name)

Address

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code) ext.

Fax No. (include area code)

Child #2

Last Name

First Name

Middle Initial

Gender

Male Female

Date of Birth (yyyy/mm/dd)

Name of Daycare/School

Grade

Address of Daycare/School

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code)

Name of Daycare Provider/Teacher (last, first name)

Does the child have any special health/education needs?

Yes No
If yes, what are they?

Provide the following information about any health/educational professionals who are involved with this child (for example, doctor, counsellor, psychologist, psychiatrist).

Professional #1

Type of Professional

Name (last, first name)

Address

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code) ext.

Fax No. (include area code)

Professional #2

Type of Professional

Name (last, first name)

Address

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Telephone No. (include area code) ext.

Fax No. (include area code)

Section VIII Custody/Access Arrangements

1. Has the court made any custody/access orders about
your child(ren)?

Yes No

If yes, please include a copy of the most recent custody/access Order(s) with your Intake Form.

2. Describe the current custody/access arrangements
for each child:

2.1 Who does/do the child(ren) currently live with?

2.2 Has/Have the child(ren) lived with the same party
since separation?

Yes No
If no, provide details about the previous arrangements and why they were changed.

2.3 Who has custody of the children (i.e., who has the right to make decisions on issues such as health and education)?

2.4 Does the other party have visits with (access to) the child(ren)?

2.5 What is the current access schedule?

2.6 If the child(ren) does/do not have any access to one of the parties, explain why.

2.7 Has/Have the child(ren) had the same access schedule
since separation?

Yes No
If no, provide details about the previous arrangements and why they were changed.

3. Describe any concerns you have about the current custody and access arrangements.

4. Describe the custody/access arrangements you would like to see for the child(ren).

5. Are you planning on moving away from your current
town/city with the child(ren)?

Yes No

If yes, have you raised the proposed move in your
court documents?

Yes No

6. How do you think we can help your child(ren)?

7. What efforts have been made to settle this case (i.e., settlement meetings, mediation)?

8. Describe your ability to communicate with the other
party about the child(ren):

Not at all
Some of the time
Most of the time
Through a Third Party
In writing only (through e-mail, letters or log book)
Other, please specify

Section IX Children’s Aid Society Involvement

1. Has the Children’s Aid Society ever been involved with
you or your children?

Yes No
If yes, concerning whom?

2. What were the concerns of the Children’s Aid Society?

Neglect
Physical Abuse
Sexual Abuse
Emotional/Psychological Abuse
Adult Conflict
Domestic Violence
Parent/Teen Conflict
Other, please specify

3. Provide the contact information for the Children’s Aid
Society if you have any current or previous involvement
with the Society.

Name of Society

Name of Worker (last, first name)

Telephone No. (include area code) ext.

Fax No. (include area code)

Address

Unit/Apt No.

Street No.

Street Name

City/Town

Province

Postal Code

Please include copies of any current Court Orders, current agreements with the Children’s Aid Society and any letters outlining the results of their investigations.

Current Involvement of the Children’s Aid Society

4. Is the Children’s Aid Society currently involved
with your family?

Yes No

If yes,

How are they involved?

currently investigating a child protection concern
currently working voluntarily with the family
currently working voluntarily with a signed Voluntary Service Agreement
there is a child protection proceeding before the court

When did the Children’s Aid Society begin their involvement? (yyyy/mm/dd)

5. Are any of your children currently living in the care of
the Children’s Aid Society (i.e., in a foster home or
group home)?

Yes No

If yes,

Name of child(ren) (last, first name)

Are they in the care of the Children’s Aid Society under a:

Temporary Care Agreement
Court Order
Kinship Arrangement

When was your child placed in the care of the Society? (yyyy/mm/dd)

Previous Involvement of the Children’s Aid
Society (Do not include information about the
current involvement of the Society in this section.)

6. Has the Children’s Aid Society been previously
involved with you or your children?

Yes No

if yes,

7. Has your case been opened more than once?

Yes No

Date of first involvement (yyyy/mm/dd)

Date last involvement ended (yyyy/mm/dd)

9. Type of prior involvement:

Investigation of a child protection concern
Voluntary involvement with the family
A signed Voluntary Services Agreement
Court Ordered Supervision Order
Child placed in the care of the Society under a Temporary Care Agreement
Child placed in the care of the Society under a Court Order

Section X Children’s Aid Society, Release of Information

Do you agree that the Children’s Aid Society
release information about yourself and the children
to us?

Yes No

If yes, complete the following

I, (first, last name) , authorize
(Name of Children’s Aid Society)
to provide information about me and my children
(Names of Children)

to The Children’s Lawyer and this shall be your good and sufficient authority for so doing. Specifically, I authorize the following questions be answered:

Is there an active child protection investigation involving this family underway now?
Are you involved with the family on a voluntary basis?
Are there child protection proceedings before the Court involving this family now?
Are any of the children in the care of the Society and if so, under what arrangement?
Have the children in this family been referred to The Children’s Lawyer for ADR?

I authorize The Children’s Lawyer to collect, use and disclose all such information obtained for the purpose of determining whether or not The Children’s Lawyer will provide services for the child(ren).

Signature

Date (yyyy/mm/dd)

Note: This release is used for the purpose of the intake process. If The Children’s Lawyer accepts your file, you will be asked to sign additional releases to allow The Children’s Lawyer to get the required information.

Section XI Violence/Abuse

1. Was there violence/abuse between you and the other party?

Yes No

2. Was the other party violent/abusive towards you?

Yes No

If yes to question 1 or 2,

When did this occur?

While you were together Since separation Currently

Type of violence:

Physical
Emotional/Psychological
Verbal
Sexual
Other, please specify

3. Were you injured?

Yes No

4. Was the other party injured?

Yes No

If yes to question 3 and/or 4, please describe:

5. Have you ever been stalked/followed/threatened by the other
party?

Yes No

6. Are you afraid of the other party?

Yes No

7. Were the child(ren) aware of the violence/abuse?

Yes No

8. Was there violence/abuse against the child(ren)?

Yes No

If yes,

By whom?

Describe the violence against the children:

Did you tell the Children’s Aid Society about the
violence/abuse to the child(ren) described above?

Yes No

Section XII Police Involvement

Before we can make a decision on the file, please note that we require copies of current:

restraining orders
probation orders
peace bonds
bail conditions

1. Have the police ever been involved with you?

Yes No

2. Have the police ever been involved with the
other party?

Yes No

If yes to question 1 or 2, indicate which police services:

Municipal OPP
RCMP
Specify the location of the police force

Restraining Orders

3. Has a court ever made a restraining order against you?

Yes No

If yes,

When was the restraining order made? (yyyy/mm/dd)

When does/did it expire? (yyyy/mm/dd)

If the restraining order has not expired, please include a copy of the restraining order.

4. Has the court made a restraining order against the
other party?

Yes No

If yes,

When was the restraining order made? (yyyy/mm/dd)

When does/did it expire? (yyyy/mm/dd)

What is the other party restrained from doing?

Current Bail Conditions

5. Are you currently subject to any bail conditions?

Yes No

If yes, attach a copy of your bail conditions.

6. Is the other party subject to any current bail conditions?

Yes No
If yes, provide details:

Criminal Convictions

7. Have you been convicted of a criminal offence, for
which you have not been pardoned?

Yes No
If yes, list the convictions:

Are you currently on probation?

Yes No

If yes, attach a copy of your probation order.

8. Do you know if the other party has been convicted of a
criminal offence?

Yes No
If yes, list the convictions:

Is the other party currently on probation?

Yes No
If yes, list any conditions that you are aware of in their probation order:

Peace Bonds

9. Are you currently subject to a peace bond?

Yes No

If yes, attach a copy of your peace bond.

10. Is the other party subject to a peace bond?

Yes No
If yes, what are the conditions of the peace bond?

Additional Information
11. Is there any other information about the involvement of the police that you want us to know?

Section XIII Health Issues

Mental Health

1. Do you have any mental health issues?

Yes No
If yes, provide details:

Have you received a diagnosis

Yes No
If yes, provide details:

Have you received any treatment for these issues?

Yes No

Type of treatment

Doctor/Psychiatrist/Psychologist
Counsellor/Therapist
Hospital
Other, please specify

Name of Mental Health Professional

Telephone No. (include area code) ext.

Address

2. Does the other party have a mental health issue?

Yes No
If yes, provide details about the mental heath issue:

3. Did the mental health issues cause problems in your relationship with the other party or the child(ren)?

Physical Health
4. Are there any physical health issues that are important to the custody/access proceedings?

Substance Abuse

5. Have you ever had a problem with substance abuse?

Yes No

If yes,

Specify the type of substance abuse:

Alcohol abuse
Drug abuse Specify type of drugs
Other, please specify

Provide details of any treatment you have received:

6. Has the other party ever had a problem with
substance abuse?

Yes No

If yes,

Specify the type of substance abuse:

Alcohol abuse
Drug abuse Specify type of drugs
Other, please specify

7. Did the substance abuse issues cause problems in your relationship with the other party or the child(ren)?

Section XIV Required Enclosures

IMPORTANT: Have you included the following information
with your Intake Form?

Copies of any completed Custody and Access Assessments (Section I)
Current Court Orders about Custody and Access (Section VIII)
Copies of any current Court Orders, current agreements with the Children’s Aid Society or letters outlining the results of their investigations (Section IX)
Copies of any current Restraining Orders, Probation Orders, Peace Bonds and Bail Conditions (Section XII)
A copy of the Court Order appointing The Children’s Lawyer in your matter

If you have not included these documents, we may not be able to review your Intake Form. Please ensure that all of these documents, if they exist, are attached to your Intake Form.

I certify that I have reviewed the above information and that I believe it to be accurate.

Signature of Party

Date (yyyy/mm/dd)

PLEASE MAKE SURE THAT YOU, NOT YOUR LAWYER, SIGN AND DATE THE FORM.