Reduced Fee Program Step 1 of 425%Your Name First Last Your Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email Are we authorized to contact you at this e-mail address? Yes NoPhoneSpouse/Co-Parent's Name First Last Spouse/Co-Parent's Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your EmployerOccupationAnnual Gross Income (before taxes)Spouse/Co-Parent's EmployerSpouse/Co-Parent's OccupationSpouse/Co-Parent's Annual Gross Income (before taxes)Information About Your Assets and DebtsFor all categories, please indicate whether the figures are joint or individual.Total of all joint bank/investment accountsJoint Figure Yes NoTotal of all separate bank/investment accountsJoint Figure Yes NoTotal of all retirement assets (401k or IRA)Joint Figure Yes NoEstimated fair market value of real estateJoint Figure Yes NoOutstanding mortgage(s)Joint Figure Yes NoStudent loansJoint Figure Yes NoTotal joint credit card debtJoint Figure Yes NoTotal separate credit card debtJoint Figure Yes NoVehiclesJoint Figure Yes NoTotal auto loansJoint Figure Yes NoTotal personal loansJoint Figure Yes NoInformation About You SituationWhat do you believe are the main issues in disputeWhat process(es) have you been involved in to date to try to resolve your issuesCheck all that apply Nothing Formal Mediation Court Action Law Enforcement/CPS OtherInformation About Your Communication and Conflict PatternsWhen you and the other party can’t agree on something, what usually happens We are usually able to work it out together Sometimes we are able to work it out together One person makes the decision We don't work it outWhen you and the other party can’t agree on something, what usually happens We are usually able to work it out together Sometimes we are able to work it out together One person makes the decision We don't work it outHow is your communication We communicate and consider the other person’s opinions We have minimal communication We tend to have a lot of conflict We tend to have a lot of conflictHow would you describe your level of trust with the other person I trust him/her/them in all important matters I trust him/her/them sometimes but not always I do not trust him/her/them at allHow do you think the other person would describe their level of trust in you Trusts me in all important matters Trusts me sometimes but not always Doesn’t trust me at allAre there any matters relevant to your dispute that you do not wish to share with the other person No, I am willing to share everything relevant I am concerned about sharing some information, but am willing to consider it I would withhold information as a negotiation strategy or for other reasons, like concern for my safetyAre you willing to speak for yourself and your own interests with the assistance of one or more Collaborative professionals, even if the conversations may be hard or uncomfortable Yes NoAre you willing to work towards a solution that takes into account what is important to the other person as much as what is important to you Yes NoInformation About Health and SafetyDo you have a support system to help you through difficult times? Always Most of the time Sometimes Not at allPlease describe your support system (e.g. family, friends, counselor, etc.)Are you having any difficulty coping with day-to-day activities or responsibilities No Sometimes Most of the time AlwaysHave there been any physical altercations (fights) between you and the other person Never Recently In the pastDo you have any concerns for your safety or the safety of another family member at this time No, no concerns Some concerns Very serious concernsAre any of the following of specific concern, for you or the other personCheck all that apply Alchohol or drugs Depression/mental health issues Damage to property Injury to pets Self-harm Threats or thoughts of suicide Financial control or manipulationIs there a restraining or protection order No YesInformation About Your Children (if applicable)Children’s names and ages (even if adult)Please specify if any of the children below are from a prior relationshipHow well do you and your spouse/co-parent communicate with one another about the children Very well Sometimes well Poorly Very poorlyIf you are separated, are you and the other parent able to agree on the amount of time the children spend with each of you Yes, we usually are able to work it out together Sometimes, but with difficulty We never seem to agreeHow often are the children exposed to the conflict between you and the other parent? Not at all 1-2 times a month 1-2 times a week AlwaysHave your children witnessed physical violence between you and the other person No YesHow important is the other parent to the well-being of your children Very important; my co-parent is a loving and involved parent Important Somewhat important Not importantI consent that information on this form may be shared with the KCCL members who coordinate this reduced-fee program and with potential professional team members.Type Full Name