Personal Data Form And Social Study Information Sheet - Tarrant County Family Court Services Page 9
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16****If you have a child with a physical or mental disability, please use the back of this page
or a separate sheet of paper to describe the disability and how it is being handled or treated.
Please attach any extra paper to this document
.
MENTAL HEALTH INFORMATION
Have you, your child(ren) or anyone involved in this case received psychiatric, psychological testing or
counseling (marital or personal) or drug or alcohol counseling or treatment?
Yes ____ No ____. If yes, please list who received counseling or treatment, when and from whom and
include the counselor’s address phone AND fax numbers.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
List any hospitalizations for psychiatric, drug or alcohol treatment for you, your child(ren) or members
of your household. Please include the name of the person who was treated, the dates of treatment,
hospital name and address and doctor’s name, address phone AND fax numbers:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
CHILD PROTECTIVE SERVICES
If you, any member of your family or household or anyone involved in this dispute has ever been involved
in an investigation for abuse (sexual or physical), neglect or lack of supervision, list name, address and
phone number of each child protective services caseworker or other investigator and the name of the
person and child who was investigated and the date of investigation.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
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