Private Child Custody Evaluators Referral List
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1
2LOS ANGELES SUPERIOR COURT
PRIVATE CHILD CUSTODY EVALUATORS REFERRAL LIST
Application
New
Renewal
PLEASE COMPLETE ALL SECTIONS AND ATTACH YOUR RESUME.
(Please note that any information provided on this form may be released to the public.)
Name:
Business Address:
Business Telephone:
E-Mail Address:
Fax:
Do you: □ Speak
□ Read
□ Write any language other than English fluently?
□ Yes
□ No If yes, indicate language/s:
LICENSE AND EXPERIENCE
Professional License #: (Attach a copy of license.)
Year Obtained:
Number of years performing child custody evaluations:
Number of child custody evaluations performed:
Do you perform brief assessments:
Yes □
No □
FEES
Fee per hour or fee per full evaluation: (Please attach a sliding scale, if applicable.)
Per hour:
Per evaluation:
Additional costs for a full evaluation (e.g. for psychological testing):
Typical cost of a full evaluation: (Do not include cost for court testimony or deposition.)
Typical cost for a brief assessment, if applicable:
Do you accept pro bono work?
Cost for court appearance?
PROCEDURES
Do you perform psychological testing?
Do you make home calls?
Areas of specialty: (Optional)
OTHER INFORMATION
Are you currently being charged, or have you ever been charged, with any violation(s) of law other
than minor traffic violations?
□ Yes □ No If yes, explain below or attach your explanation.
CHILD CUSTODY EVALUATOR TRAINING AND EDUCATION
PURSUANT TO CRC 5.225
40 hours education and training: (Attach certificate of attendance if a new application.) Date:
Annual 8 hours of continuing education and training: (Certificate of attendance attached.)
Date:
DOMESTIC VIOLENCE TRAINING AND EDUCATION
PURSUANT TO CRC 5.230
12 hours training: (Attach certificate of attendance if a new application.)
Date:
Annual 4 hours update training: (Certificate of attendance attached.) Date:
I declare under penalty of perjury under the laws of the State of California that the aforementioned is
true and correct.
Signature: _________________________________
Date: _________________________
Rev. March 2012
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