Intake questionnaire

Date *

MM

DD

YYYY

I expressly consent to the collection of the within information for the purposes of my summary discussions with Tracy L. Clark and any subsequent engagement of her services. *

Yes

How did you hear about our firm?

Phonebook

Internet

Referred by Friend

Other

Name *

First Name

Last Name

Your Spouse/Partner

First Name

Last Name

New Spouse

First Name

Last Name

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Employment Start Date

MM

DD

YYYY

Birthdate

MM

DD

YYYY

Are either you or your spouse/partner in bankruptcy?

Yes

No

Do you or your spouse/partner have a disability or medical condition?

Yes

No

Your Spouse's Name

First Name

Last Name

Your Spouse's Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Spouse's Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Spouse's Home Phone

(###)

###

####

Your Spouse's Cell Phone

(###)

###

####

Your Spouse's Work Phone

(###)

###

####

Your Spouse's Employment Start Date

MM

DD

YYYY

Your Spouse's Birthdate

MM

DD

YYYY

Date you started living together

MM

DD

YYYY

Have you separated from your spouse/partner?

NO

YES - but we still live together in the Family Residence

YES - we no longer live together

Date of Separation

MM

DD

YYYY

Are you and your spouse/partner married?

Yes

No

Date of Marriage

MM

DD

YYYY

Your Marital status at time of Marriage

Divorced

Never previously married

Widowed

Your Spouse's Marital status at time of Marriage

Divorced

Never previously married

Widowed

Has there been any violence in your relationship?

Yes

No

Have you entered into any sort of an agreement (prenuptial or otherwise) with your spouse/partner?

Yes

No

Has either Party started Court proceedings

Yes

No

Are there any Court dates set?

Yes

No

Have any Orders been issued in the past with respect to your family matter?

Yes

No

Child One - Name

First Name

Last Name

Birthdate

MM

DD

YYYY

Biological child of both parents?

Yes

No

Your step-child?

Yes

No

Your child from a previous relationship?

Yes

No

Child Two - Name

First Name

Last Name

Birthdate

MM

DD

YYYY

Biological child of both parents?

Yes

No

Your step-child?

Yes

No

Your child from a previous relationship?

Yes

No

Child Three - Name

First Name

Last Name

Birthdate

MM

DD

YYYY

Biological child of both parents?

Yes

No

Your step-child?

Yes

No

Your child from a previous relationship?

Yes

No

Who was the primary caregiver prior to separation?

YOU

YOUR SPOUSE

SHARED

Who has been the primary caregiver since separation?

YOU

YOUR SPOUSE

SHARED

Who should have primary care of the Children now?

YOU

YOUR SPOUSE

SHARED

Is the other parent unfit?

Yes

No

Is support being paid?

Yes

No

FAMILY RESIDENCE Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this a mobile home?

Yes

No

What would you like to do with the home?

KEEP IT

SELL IT

GET BUY OUT FROM SPOUSE

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this a mobile home?

YES

NO

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this a mobile home?

YES

NO

JOINT

YOURS

YOUR SPOUSE'S

JOINT

YOURS

YOUR SPOUSE'S

JOINT

YOURS

YOUR SPOUSE'S