dCOURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

HAMILTON COUNTY, OHIO

PRIVATE CUSTODY EVALUATOR APPLICATION CHECKLIST

Name:

Application Date:

Qualifications

1. Master’s degree or higher,

2. License in the State of Ohio or physician licensed in any state or license in another jurisdiction with authorization by the Ohio Board of Psychology

3. Supreme Court of Ohio Pre-Appointment Training

Documents

1. Application (DR 12.1)

2. Resume

3. Supreme Court of Ohio Pre-Appointment Training Certificate of Completion

4. Proof of malpractice insurance

5. Copy of current licensure

Qualified to Serve

Yes No

Comments:

Reviewed and approved by: Date: