Small Group Phone Coaching For Estranged Parents (form only) Phone Coaching For Estranged Parents Intake interview Name First Last Email* Phone*Current age of your child or childrenLast time you saw your estranged child or childrenDo you have any contact at all such as email, phone?Will he or she take your calls, gifts, etc. or have you been blocked and told not to contact him or her ever again?Have you ever been threatened with a restraining order or told that he or she would call the police?Is he or she in contact with other family members?YesNoNot SureAre you allowed to see the grandchildren?YesNoNot ApplicableWere you ever allowed to see the grandchildren?YesNoNot ApplicableWhat is his or her stated reason for the estrangement?What is your belief about why the estrangement occurred?What was your child like growing up? Were there any problems with other children, moodiness, learning disabilities, Attention Deficit Disorder, drug or alcohol abuse?What is your child’s current relationship status?MarriedDivorcedLiving with someone?SingleWhat is your current relationship status?MarriedDivorcedLiving with someoneSingleIf you’re divorced, does your child or children have contact with your ex?What is your relationship like with your ex?What other current problems or conflicts are you experiencing either as a result of the estrangement or in addition to it? Please include both psychological and physical problems (eg cancer, physical disabilities, etc).Briefly, what was your childhood like? Were your parents close, distant, in conflict? Did they divorce?What is the most challenging aspect of the estrangement for you? For example, “How it affects my self-esteem,” “Feeling hopeless and suicidal” “Panic and other forms of anxiety” “Ongoing depression,” “Inability to be productive,” etc.Please include anything else that you think would be important for me to know.What time zone do you live in?EmailThis field is for validation purposes and should be left unchanged.