High Conflict Diversion Program Class Form

Tuesday Classes - Online & In-person

Parents - please complete this intake form prior to taking the High Conflict Divorce Program parenting class. All fields are required.

Are you interested attending class online or in-person?

Live Online Class
Live In-Person Class

Please indicate if you are interested attending classes online or in-person.

First Name

Please make sure you have correctly entered your first name.

Last Name

Please make sure you have correctly entered your last name.

Email address

Please make sure you have correctly entered your email address.

Phone Number with Area Code

Please make sure you have correctly entered your phone number and area code.

Street Address 1

Please make sure you correctly enter your street address.

Street Address 2

Please make sure you correctly enter your suite or unit number.

City

Please make sure you have correctly entered the name of your city.

State

Please make sure you have selected your state from the drop-down.

Zip Code

Please make sure you have correctly entered your zip code.

Other Parent's Name

Please list the name of the other parent.

Judge assigned to case

Please type the name of the judge assigned to your case.

Your attorney’s name

Please enter the name of your attorney.

Other parent attorney’s name

Please enter the name of the other parent's attorney.

First child's name

Please enter the name of your first child.

First child's age

Please enter the age of the first child.

Second child's name

Please enter the name of your second child.

Second child's age

Please enter the age of the second child.

Third child's name

Please enter the name of your third child.

Third child's age.

Please enter the age of the third child.

Fourth child's name

Please enter the name of your fourth child.

Fourth child's age.

Please enter the age of the fourth child.

Fifth child's name

Please enter the name of your fifth child.

Fifth child's age.

Please enter the age of the fifth child.

Sixth child's name

Please enter the name of your sixth child.

Sixth child's age.

Please enter the age of the sixth child.

How long have you been separated/ divorced?

Please indicate how long you have been separated/ divorced.

Briefly describe the issues that are part of the conflict between you and the other parent.

Please use the text area to briefly describe the issues that are part of the conflict between you and the other parent.

How many times have you been to Family Court Services or Family Court in the last 2 years?

Please select the number from the drop-down that indicates how many times have you been to Family Court Services or Family Court in the last 2 years.

Is there an attorney assigned to your child or children?

Yes No

Please indicate if an attorney is assigned to your child or children.

Has there been a psychological evaluation completed or ordered for you?

Yes No

Please indicate if there been a psychological evaluation completed or ordered for you.

Has there been a psychological evaluation completed or ordered for your spouse?

Yes No

Please indicate if there been a psychological evaluation completed or ordered for your spouse.

Is this a divorce or paternity case?

Divorce Paternity

Please indicate if this a divorce or paternity case.

Do you have a personal history or experience with high conflict divorce or custody?

Yes No

Please indicate if you have a personal history or experience with high conflict divorce or custody.

Is there anything else you would like us to know?

Please let us know if there is anything else you would like us to know,

What would you like to learn from this program?

Please describe what you would like to learn from this program.

Please use the I Agree button to confirm your consent and submit your application.

Get our Free Booklet

The High Conflict Diversion Program textbook was created to support the classroom experience of learning about parenting in a high conflict divorce or custody dispute.

Get It Now