Goldberg & Associates

Please fill out the following questionnaire and include your contact information ( telephone and email ). We will provide you with a FREE CONSULTATION to assist you. All information will remain confidential.

Your name is:
Your email address is:
Your Telephone Number is:


1. Are you currently having difficulty with visitation to see your children?
Constant Difficulty       Moderate Difficulty       Little Difficulty       No Difficulty

2. Does your spouse claim that the children do not want to see you for visitation?
Yes       No       Frequently       Infrequently

3. Do your children tell you that they do not want to see you for visitation?
Yes       No       On Occasion       Only Recently

4. Are there significant financial disputes going on between you and your spouse?
Yes       No

5. Has your child or any of your children complained that they are suddenly fearful of you?
Yes       No

6. Has your spouse made any accusations of abuse against you?
Yes       No

7. Have the police been involved in a domestic dispute since your separation with your spouse?
Yes       No

8. Does your spouse have relatives saying negative things about you in front of your children?
Yes       No       I am not sure      

9. Does your spouse say negative things about you in front of your children?
Yes       No       I am not sure      

10. Do you have any difficulty seeing your children at school activities, at social functions, on any holidays or special events?
Always       Frequently       Sometimes       No      

11. When you discuss visitation with your spouse do you have arguments?
Always       Frequently       Sometimes       No      

12. Have any of your children expressed a desire to not want to live with you?
Yes       No

13. Do you notice any of your children having a sudden loss of affection for you?
Yes       No       Maybe      

14. Does your spouse exhibit significant anger towards you?
Yes       No

15. Do you think that you and your spouse can develop a compatible co-parenting relationship for the sake of the children?
Yes       No       Maybe      

16. Does your spouse block telephone contact between you and your children?
Yes       No       Not Sure      

17. Has your spouse taken your child to a therapist without your notification and informed consent?
Yes       No       I Don't Know      

18. Did your spouse mention any plans to relocate at anytime in the near future?
Yes       No

19. Do any of your children have constant complaints about their health, or express to you that they are having emotional distress of any kind related to parental conflicts?
Yes       No       Not That I Am Aware Of      

20. The name of your attorney is and his phone number is .


Parental Alienation Consultant:
Expert in Parent-Child Relational Problems. Services are provided to family law lawyers,
mental health professionals, mandatory state providers of divorce education programs and to parents.