Parent Coordinator Application Form
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8PARENT COORDINATOR APPLICATION
TH
11
JUDICIAL CIRCUIT OF FLORIDA
FAMILY COURT DIVISION
Forward When Completed To:
Family Court Services, Lawson E. Thomas Courthouse Center
st
175 NW 1
Avenue, Suite 1503, Miami, Fl 33128 Tel: (305) 349-5508 Fax: (305) 349-5634
Name:
Present Employment:
Organization:
Office Address:
City:
State:
Zip:
Telephone:
Fax:
E-mail:
Social Security Number:
-
-
Driver License Number:
Date of Birth:
Place of Birth:
City & State
Languages fluent in other than English:
QUALIFICATIONS
PROFESSIONAL REQUIREMENT. Check all that apply and insert licensure or certification
number(s):
□
Licensed Mental Health Professional under Florida Chapter 490 or 491, #_____________
□
Physician under Florida Chapter 458 with Certification by American Board of Psychiatry
and Neurology, #__________
□
Florida Supreme Court Certified Family Law Mediator with at least a master’s degree in a
mental health field, #___________
□
Member in good standing of The Florida Bar, #__________
PARENTING COORDINATOR REQUIREMENTS. Check all successfully completed:
□
Three years post licensure or post certification practice in any one of the professions
checked above.
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