Intake Form

client information worksheet
Home / Intake Form

Please fill out all 5 pages of the form below.  You may leave a response blank if you do not have the information requested or are unsure of the response.

Name
If wife, maiden name
If wife, request return of maiden name?
Email
Home phone
Cell phone
Address:
Preferred method of contact?
Birthdate
Birthplace
Spouse Name
If spouse wife, maiden name
If spouse wife, request return of maiden name?
Spouse email
Spouse home phone
Spouse cell phone
Spouse address
Spouse birthdate
Spouse birthplace
Year last filed taxes
Tax filing status
Number of exemptions claimed
State(s) in which taxes filed
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Highest grade completed
College attended
Number years college completed
Year graduated
Degree
Graduate school attended
Number years grad school completed
Grad school year graduated
Graduate degree
Professional/ occupational license
Vocational training
Current employer
Position
Date started
Work address
Yearly salary
# hours work/ week
Spouse highest grade completed
Spouse college attended
Spouse year graduated
Spouse degree
Spouse graduate school attended
Spouse grad school year graduated
Spouse graduate degree
Spouse current/ last employer
Spouse position
Spouse work address
Spouse date started
Spouse yearly salary
Spouse # hours work/ week
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Date of Marriage
County and state of marriage
Date of Separation
Length of time in California
Length of time in County
Spouse length of time in California
Spouse length of time in County
Previous marriage(s):
If so, how terminated?
Spouse previous marriage(s):
If so, how terminated?
Petition for:
If dissolution, grounds for:
If nullity, grounds for:
Any pre-marital agreements?
If so, desire to challenge?
Any post-marital agreements/ family trusts?
Are you interested in marriage counseling?
Are you interested in mediation or collaborative law?
Any history of domestic abuse?
Any history of child abuse?
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Number of living children of marriage (born or adopted)?
Number of deceased children of marriage?
Child 1 Name
Child 1 Birthdate
Child 1 Birthplace
Child 1 Sex
Child 2 Name
Child 2 Birthdate
Child 2 Birthplace
Child 2 Sex
Child 3 Name
Child 3 Birthdate
Child 3 Birthplace
Child 3 Sex
Child 4 Name
Child 4 Birthdate
Child 4 Birthplace
Child 4 Sex
Have you participated in any capacity in any litigation concerning the custody of the children in a court in this or any other state?
If yes, please provide details:
Do you have any information regarding any custody proceeding concerning the children in a court in this or any other state?
If yes, please provide details :
Do you know of any person not a party to the within proceeding who has physical custody of the above-named children or who claims to have custody or visitation rights with respect to the children?
If yes, please provide details
Do you desire legal custody of the children?
Do you desire physical custody of the children?
Will the other side seek custody of the children?
Approximate percentage of time Mother has primary physical responsibility for the children:
Approximate percentage of time Father has primary physical responsibility for the children:
If custody will be at issue, state reasons why you should have custody:
Do you desire any special terms regarding visitation?
Does either parent have any plans to move out of the area?
Monthly cost for insurance paid by you or on your behalf for the children only:
Is health insurance for the children available through your employer?
Name of carrier:
Address of carrier:
Policy or group policy number:
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Please describe any areas of conflict you anticipate:
Please describe any areas of concern that you have:
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