| Grantee and/or Sub-Grantee Information |
Service Provided &Client Participation (Values M (Mandatory), V (Voluntary) B (Both) |
U, R, B |
Client Referral Source |
Client Information |
|
Child Support Cases (Optional) |
Marital Status |
Race/Ethnicity |
Annual Income |
Services Provided |
Frequency of Service ( Hours) (Optional) |
Outcome#1-Parenting Time (Required) |
Outcome#2 - Knowledge of Effective Co-Parenting Strategies (Optional) |
| Name of Grantee and/or Sub-Grantee |
Title of AV Program |
Contact Name |
Address Line 1 |
City |
State |
Zip |
Grant Amount |
Grant Period From Date |
Grant Period To Date |
Mediation |
Development of Parenting Plan |
Counseling |
Parent Education |
Neutral Drop-off/Pick-up |
Supervised Visitation |
Visitation Enforcement |
Geographic Area Served |
Self |
Court |
Child Support Agency |
Domestic Violence Agency |
Child Protection Agency |
Other |
Data Not Reported |
NCP Father |
CP Father |
NCP Mother |
CP Mother |
Grandparent/Legal Guardian |
Number of Children in Common |
NCP Father |
CP Father |
NCP Mother |
CP Mother |
Grandparent/Legal Guardian |
Never Married to Each Other |
Married to Each Other |
Separated From Each Other |
Divorced From Each Other |
Data Not Reported |
American Indian or Alaska Native |
Asian |
Black or African American |
Hispanic or Latino |
Native Hawaiian or Other Pacific Islander |
White |
Two or More Races |
Other |
Data Not Reported |
Less than $10,000 |
$10,000 to $19,999 |
$20,000 to $29,999 |
$30,000 to $39,999 |
$40,000 & Above |
Data Not Reported |
Mediation |
Development of Parenting Plan |
Counseling |
Parent Education |
Neutral Drop-off/Pick-up |
Supervised Visitation |
Visitation Enforcement |
Mediation |
Development of Parenting Plan |
Counseling |
Parent Education |
Neutral Drop-Off/Pick-Up |
Supervised Visitation |
Visitation Enforcement |
NCP Fathers |
NCP Mothers |
NCP Fathers |
CP Fathers |
NCP Mothers |
CP Mothers |