FAMILY MEDIATION SERVICES QUESTIONNAIRE



Please read and follow the Instructions.

Upcoming Parent Education Seminar/Webinar Registration is enrolled online only!

Below you will find 2 forms. The (Co-Parenting Questionnaire) is your registration form. The (Parent Education Evaluation) is to be completed and returned after the webinar. You should be able to type on the Microsoft Word document, save and send it back. If not download the pdf file and send it back as directed. These forms can be emailed, scanned, faxed or text pic. Fax: 757.242.6723 or email to Dparks7881@.

The price of the webinar is $50.00 plus $2.75 processing fee. Click the PayPal Link on the webpage to make your payment. Funds are sent to DParks7881@. **If you are making payment for someone else, annotate that in the notes area as well as provide an email address to whom the link is to be sent. You may also mail payments to DP Mediation Services, LLC (DPMS) P.O. Box 558 Windsor, VA 23487. Cashier’s Checks or Money Orders are accepted.

After the completion of the webinar, you will be emailed the certificate of completion that is to be provided to the court as proof of attendance of a Parenting Education Seminar/Webinar.

**You will receive the link to the seminar/webinar after payment is made or at least one day prior to the webinar. This link will go to the email address listed in the PayPal payment information or from your registration form. Download GoToMeeting and test the link prior to the webinar. Please have your cameras on and keep your device/phone on mute when entering the session.

Should you have any questions or concerns, please contact me directly at 757.570.8886

Daryl A. Parks

Instructor

CO- PARENTING QUESTIONNAIRE

Email Address:_________________________________ Class Date/Time: ________________________

Please provide the following information as fully and completely as you can. This information is kept confidential.

1) NAME : ____________________________________________________________________________________________

As you want on the certificate (First) (Middle Initial) (Last)

STREET ______________________________________________CITY____________________________________________

STATE ____________________________ ZIP CODE _____________________________________

HOME #__________________________________ CELL#_____________________________________

2) RELATIONSHIP TO THE CHILD(REN): ( Mother ( Father ( Grandparent ( Step-parent

( Legal Guardian ( Other (list):___________________

3) THE CHILD(REN) LIVES WITH: ( Mother ( Father ( Grandparent ( Step-parent

( Legal Guardian ( Other (list):_______________________

4) IS THERE A CURRENT PROTECTIVE ORDER IN EFFECT? ( yes ( no

5) ARE YOU IN THE PROCESS OF SEPARATING/DIVORCING YOU CHILD(REN)’S CO-PARENT? ( yes ( no

6) WOULD YOU LIKE TO LEARN HOW MEDIATION COULD ASSIST YOUR FAMILY? ( yes ( no

7) WHICH COURT / WHO REFERRED YOU TO THIS COURSE? __________________________________________

________________________________________ ___________________________________

(SIGNATURE) (DATE)

Parent Education Seminar Evaluation

Co-Parents, Two Parents, Two Homes

Presented by: DP Mediation Services, LLC Instructor: Daryl A. Parks

Seminar Date: Name:

1. Name of Court Where Case is Filed: ___________________________________________________

Poor Needs Average Very Excellent

Improvement Good

2. Knowledge of subject 1 2 3 4 5

3. Presentation skills 1 2 3 4 5

4. Interaction with participants 1 2 3 4 5

5. Usefulness of slides 1 2 3 4 5

6. What part of the seminar did you find most helpful?

7. What part of the seminar did you find least helpful?

8. List one thing that you learned from the seminar.

9. Were the directions to the seminar helpful? ___Yes ___No

If not, why not?

10. Was the facility appropriate for this seminar? ___ Yes ___ No

Was this a convenient location? ___ Yes ___ No

Do your prefer in-person seminar ___ virtual webinar ___ the option of both ___

11. Additional comments – your take away, course improvements or topics discussed in the class.

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