Request For Inclusion On The Parenting Coordinator List {WAKE-DOM-25}

Request for Inclusion on the Parenting Coordinator List Name: ___________________________________ Address: _____________________________ _____________________________ Attorney Firm Name: ________________________ Phone: ________________________ Fax: ________________________ Wake County Attorney Mailbox #: _________________________ Email: ________________________________________________________ THIS SECTION MUST BE COMPLETED FOR INCLUSION I certify the following: (Check all that apply) I hold a masters or doctorate degree in psychology, law, social work, counseling, medicine, or a related subject area. Degree (specify in which area): _____________________________ University/College: _______________________________ Year Obtained: ___________ I have at least five years of related professional post-degree experience. I hold a current license in my area of practice. Area of Practice: __________________________ License Number: __________________________ Not Applicable (list why): ________________________________________________________ I have attached a copy of my current resume or curriculum vitae. I have completed 24 hours of training in topics related to the developmental stages of children, the dynamics of high-conflict families, the stages and effects of divorce, problem solving techniques, mediation, and legal issues. I have attached documentation that clearly indicates that the above 24 hours of training requirement has been satisfied (e.g. list the trainings, dates, hours, and locations). I agree to attend parenting coordinator seminars that provide continuing education, group discussion, and peer review and support. I understand, that per HB Section 50-93, I must attend parenting coordinator seminars that provide continuing education, group discussion, and peer review and support to remain eligible to serve as a Parenting Coordinator. I will keep the Family Court Office informed of any changes in my contact information. I will contact the Family Court Office if I become ineligible to continue to serve as a Parenting Coordinator. I understand that the Chief District Court Judge will remove my name from the Parenting Coordinator List if I become ineligible to continue to serve as a Parenting Coordinator. This the ______ day of ____________________, 20_____. (Signature) _______________________________ WAKE-DOM-25 (02/06) (PAGE 1 of 2) American LegalNet, Inc. www.USCourtForms.com For use by the District Court Judges' Office Only: Request for Inclusion on the Parenting Coordinator List Approved Denied: ____________________________________________________ Chief District Court Judge (or designee) Date: ________________________________________ WAKE-DOM-25 (02/06) (PAGE 2 of 2) American LegalNet, Inc. www.USCourtForms.com