Counselling Referral List Application
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1
2LOS ANGELES SUPERIOR COURT
COUNSELING REFERRAL LIST
Application
New
Renewal
PLEASE COMPLETE ALL SECTIONS.
(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 languages:
LICENSE AND EXPERIENCE
(Attach a copy of license and current resume.)
Professional License Number:
Year Obtained:
Number of years experience counseling children & families:
Number of years counseling families involved in custody disputes:
Percentage of practice currently consisting of families involved in custody disputes:
Areas of specialty: (optional)
FEES
Fee per hour: (Please attach sliding scale, if applicable.)
Do you accept pro bono work?
Cost for court appearance:
PROCEDURES
Do you perform psychological testing?
Under what circumstances will you provide a report back to the judge who ordered the counseling?
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.
Please provide a list of all the continuing education courses you have taken in the last five years pertaining to
custody disputes. List any course you have taken in the last five years pertaining to domestic violence.
(Attach certificates.)
I declare under penalty of perjury under the laws of the State of California that the aforementioned is
true and correct.
Signature: _________________________________
Date: _________________________
Rev. 7/12
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Parent category: Legal