The Law Office of WLP

SAPCR/GUARDIANSHIP

The Law Office of Whitney L. Thompson, PLLC Please complete this questionnaire. If you spend the time to complete all items, you will give us the background information necessary to begin to understand the complexity of the personal aspects of your case. All information will be held in strict confidence.
Today's Date *

Month Day Year
Client's Name *

First Name Last Name
Client: Have you used any other alias names? *

Yes No
If Yes, list of other alias names. *
Client's DOB *

Month Day Year
Client's Age *
Please enter your current age.
Client's Sex *

Female Male
Client's Place of Birth *
City, Texas
Client: Do you have a Driver License Number? *

Yes No
Client's Driver License Number
Do not use any dashes or other symbols
Client: Are you a US Citizen *

Yes No
Client: Do you have a SSN? *

Yes No
Client's SSN *
This information will be kept confidential. Do not use any dashes or other symbols
Client's Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What County do you reside in? *
How long have you resided in your County?
How long have you lived in Texas?
Do you want to receive mail from our office to a different address? *

Yes No
Client's Preferred Mailing Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Client's E-mail Address *
Enter an email address you would like to be contacted at about your case.
Client's Phone Number *

Area Code Phone Number
Client's Highest Education Level:
Client: Are you employed? *

Yes No
Client: When was your last employer and with who? *
Name of last employer & when
Client: How long have you been employed with your current employer? *
years or months
Client's Employer's Name *
Client's Supervisor's Name
Current Employer Supervisor
Monthly Net Income (after taxes)
Client's Job Title:
Client's Work Number

Area Code Phone Number
Client's Work Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your Relationship to the Child: *
Are you married? *

Yes No
If YES, (1) how long have you been married and (2) where did you get married? *
Other Adults/Children Who Live In Your Home

Please list all adults and children who live in your home
Please list the following information for each person who lives in your home (adult or child not part of this case) (1) Name (2) Age and (3) Date of Birth *
Other Person(s) Involved in Child Custody or Guardianship Case

Please provide the information for other person(s) who are seeking custody or guardianship, including biological parents, family members, or etc.
Are you the mother of the child(ren)/person(s) in this case? *

Yes No
(1) Mother's Full Name *

First Name Last Name
(1) Mother's DOB

Month Day Year
(1) Mother's Age
(1) Mother's Place of Birth
City, State
(1) Does mother have a Driver License Number?

Yes No Not Sure
(1) Mother's Driver License Number
Please do not use dashes.
(1) Mother: US Citizen? *

Yes No
(1) Mother: Does she Have a SSN?

Yes No Not Sure
(1) Mother: SSN
Please do not use dashes.
(1) Mother's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
(1) Mother's Phone Number *

Area Code Phone Number
(1) Mother's Highest Education
(1) Is Mother Employed? *

Yes No
(1) Mother's Job Title:
(1) Name of Mother's Employer:
(1) Mother's Employer's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
(1) Mother's Employer's Phone Number

Area Code Phone Number
(1) Mother's Net Monthly Income (after taxes)
Are you the father of the child(ren)/person(s) in this case? *

Yes No
(2) Father's Full Name *

First Name Last Name
(2) Father's DOB

Month Day Year
(2) Father's Age
(2) Father's Place of Birth
City, State
(2) Does Father have a Driver License Number? *

Yes No Not Sure
(2) Father's Driver License Number
Please do not use dashes.
(2) Father: US Citizen? *

Yes No
(2) Father: Does he Have a SSN? *

Yes No Not Sure
(2) Father's: SSN
Please do not use dashes.
(2) Father's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
(2) Father's Phone Number *

Area Code Phone Number
(2) Father's Highest Education
(2) Is Father Employed? *

Yes No
(2) Father's Job Title:
(2) Name of Father's Employer: *
(2) Father's Employer's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
(2) Father's Employer's Phone Number

Area Code Phone Number
(2) Father's Net Monthly Income (after taxes)
Do you need to include another person's information that is seeking custody? *

Yes No
(3) Person's Relationship to the Child(ren)/Person(s) *
(3) Person's Full Name *

First Name Last Name
(3) Person's DOB

Month Day Year
(3) Person's Age
(3) Person's Place of Birth
City, State
(3) Does person have a Driver License Number? *

Yes No Not Sure
(3) Person's Driver License Number
Please do not use dashes.
(3) Person: US Citizen? *

Yes No
(3) Person: Does he/she Have a SSN? *

Yes No Not Sure
(3) Person: SSN
Please do not use dashes.
(3) Person's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
(3) Person's Phone Number *

Area Code Phone Number
(3) Person's Highest Education
(3) Is Person Employed? *

Yes No
(3) Person's Job Title
(3) Name of Person's Employer: *
(3) Person's Employer's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
(3) Person's Employer's Phone Number

Area Code Phone Number
(3) Person's Net Monthly Income (after taxes)
Additional Information Regarding Parents/Adults

Please provide this additional information for our office to fully evaluate your case.
Are there any Court dates pending in this matter? *

Yes No
If YES, when? *

Month Day Year
If YES please provide (1) Name of the Court (2) Name of the Judge (3) Date the Case was Filed (4) Cause No. (5) Status of the Case: *
Has the biological mother been served (if necessary)? *

Yes No Not Applicable
Does the mother agree to the child custody or guardianship case? *

Yes No Not Applicable
Does the mother have the child(ren)/person now? *

Yes No Not Applicable
If NO, explain the reason why she does not have the child(ren)/person(s): *
Has the biological father been served (if necessary)? *

Yes No Not Applicable
Does the father agree to the child custody or guardianship case? *

Yes No Not Applicable
Does the father have the child(ren)/person(s) now? *

Yes No
If NO, explain the reason why he does not have the child(ren)/person(s): *
Will there be a dispute over custody/guardianship? *

Yes No
If NOT, what is the the custody/guardianship arrangment? *

Check any of the following which are applicable in the case: *

Myself (As a Non-Parent)

Mother

Father

All

Not Sure

Illegal Drug/Alcohol

Sexual Disappointment

Sexual Infidelity

Financial Disputes

Physical Violence

Religion

Incompatibility

Mental Health Issues

Committed a Felony

Been Arrested

Been in Jail or Prison

Prescription Drugs

Arrested for DWI

Arrested for DUI

Gambling (legal or illegal)

Attempted Suicide

Hospitalize for Emotional or Psychiatric Treatment

Child Abuse

Adultery

Homosexual relationships

Engaged in Unusual Sexual Preferences

Pregnancy Outside the Marriage

Sexual Transmitted Disease

Left child(ren) with intent to return

Left for 3 months without expressing intent to return

Left for 6 months without providing support

Placed or allowed the child(ren) in dangerous conditions

Conduct that engages the child(ren)

Failed to support the child(ren) for one year

Abandoned the child(ren) without identifying them

Abandoned the mother during pregancy

Refused to submit to a court''s order

Causes or has caused the child to be absent from school

Executed an affidavit of relinquishment

Injured the child(ren)

Terminated parental rights with regard to another child

Please describe any of the above situations you below: *
Provide as much detail as possible.
Does the child(ren) or person(s) you are seeking custody or guardianship of live with you? *

Yes No
If YES, how long has the child or person lived with you? *
Please list all Child(ren)/Person(s) You are Seeking Custody or Guardianship Of:

Please list all the information for each child or person below
(1) Name of Child/Person *

First Name Last Name
(1) Sex of the Child/Person *

Female Male
(1) DOB of the Child/Person

Month Day Year
(1) Place of Birth of the Child/Person:
City, State
(1) Child's/Person's SSN
Please do not include any dashes.
(1) Do you need to list another child/person? *

Yes No
(2) Name of Child/Person *

First Name Last Name
(2) Sex of the Child/Person *

Female Male
(2) DOB of the Child/Person

Month Day Year
(2) Place of Birth of the Child/Person:
City, State
(2) Child's/Person's SSN
Please do not include any dashes.
(2) Do you need to list another child/person? *

Yes No
(3) Name of Child/Person *

First Name Last Name
(3) Sex of the Child/Person *

Female Male
(3) DOB of the Child/Person

Month Day Year
(3) Place of Birth of the Child/Person:
City, State
(3) Child's/Person's SSN
Please do not include any dashes.
(3) Do you need to list another child/person? *

Yes No
(4) Name of Child/Person *

First Name Last Name
(4) Sex of the Child/Person *

Female Male
(4) DOB of the Child/Person

Month Day Year
(4) Place of Birth of the Child/Person:
City, State
(4) Child's/Person's SSN
Please do not include any dashes.
(4) Do you need to list another child/person? *

Yes No
(5) Name of Child/Person *

First Name Last Name
(5) Sex of the Child/Person *

Female Male
(5) DOB of the Child/Person

Month Day Year
(5) Place of Birth of the Child/Person:
City, State
(5) Child's/Person's SSN
Please do not include any dashes.
(if necessary please bring in a separate sheet of paper with additional names and information).
For each child or person you are seeking custody or guardianship of, state for the last FIVE years each place that the child or person have lived include the following information (1) full address (2) the dates that the child or person lived at that address and (3) with whom did the child or person live with: *
Describe the child's or person's reaction and feeling to each person who is seeking custody or guardianship in this case. *
Does the child(ren) or person you are seeking custody or guardianship of have health insurance? *

Yes No
If Yes, please provide the following information below: 1. Health Insurance Company 2. Policy Number 3. Source of Insurance 4. Cost of Premium and 5. Who pays the Premium each month
Please provide as much information as possible. This information is needed for the court.
Does either person have access to private health insurance at a reasonable cost? *

Mother Father Both Not Sure
Has anyone ever applied for Medicaid or Medicare benefits for the child or person you are see custody or guardianship of? *

Yes No Not Sure
If YES, please provide (1) applied for the benefits and (2) what is the status of the application below: *
Do the children/person you are seeking guardianship of own any property other than (clothing or furniture)? *

Yes No
If Yes, please list all property. *
Please provide as much detail as possible.
Who owes a duty to support other children who are not party of this case? *

Mother Father Mother and Father Relative/Other Person Seeking Custody Relative/Other Person Seeking Custody and Mother Relative/Other Person Seeking Custody and Father All None

If either party is subject to a a court order for child support, please provide as much information as possible: *
Emergency Contact

This is a person(s) who you would like for our office to contact about your pending case if you are not able to be reached.
Emergency Contact's Name

First Name Last Name
Emergency Contact's Relationship to You:
Emergency Contact's Phone Number

Area Code Phone Number
Emergency Contact's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Miscellaneous

Please answer the following questions.

Which parties are represented by an attorney now in this matter? *

Yes

Not Sure

Mother

Father

Other Relative/Person Seeking Custody

What are the circumstances surrounding this case? *
What are your goals in this case? *
If you are not the child(ren)'s or person(s)'s biological parent and you are seeking custody or guardianship, is your long term goal to adopt the child(ren)/person(s)? *

Yes No Not Application
If NO, what is your long term goal? *
Have either of the parties every taken any photos or visual records of the other party that may be used against the other party in the case? *

Yes No
If YES, please describe the content of the photos or visual recording below: *
Do you or the other party suffer from any physical disability that would interfere with with the ability of caring for the child(ren) or person you are seeking custody or guardianship of? *

Yes No
If YES, state please explain below: *
Closing Questions
Did someone refer you to our office? *

Yes No
Name of the Person who Referred You: *

First Name Last Name
Have you consulted or retained any other attorneys on this matter before? *

Yes No
If Yes, please state who you consulted with and when: *
Should be Empty:

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SAPCR/GUARDIANSHIP

Other Adults/Children Who Live In Your Home

Other Person(s) Involved in Child Custody or Guardianship Case

Additional Information Regarding Parents/Adults

Please list all Child(ren)/Person(s) You are Seeking Custody or Guardianship Of:

Emergency Contact

Miscellaneous

Closing Questions