Family Law Intake Form

Client Information
Your Full Name: *

First Middle/Initial Last
Your Birthdate *

Month Day Year
Your Soc. Sec. Number
Your Residential Address

Street Address

Street Address Line 2

City State

Zip Code
Employer Name:
Position:
Years at this Employment:
Gross Annual Income:
Employer Address

Street Address

Street Address Line 2

City State

Zip Code
Spouse Information
Spouse's Full Name: *

First Name Middle Name Last Name
Spouse Birthdate *

Month Day Year
Soc. Sec. Number
Residential Address

Street Address

Street Address Line 2

City State

Zip Code
Employer:
Position:
Gross Annual Income:
Years at Employer:
Cell Phone Number

Area Code Phone Number
E-mail *
Marriage Information
Date of Marriage? *
Parties Still Reside Together?

Yes No
Date Marriage/Relationship Broke Down?

Month Day Year
Date
Date of Separation?
Maiden Name of Wife:
leave blank if wife already using maiden name
Child1 Full Name:
Age:
Date of Birth
Child2 Full Name:
Age:
Date of Birth
Child3 Full Name:
Age:
Date of Birth
State current parenting time (custody/visitation) arrangement for the children, and any preferences or agreements reached.

What Issues are in dispute?

Client Information