Client Intake Questionnaire

Residence Address

Mailing (If different than above ) / Address

EMPLOYER

Address

Total Gross Income Last Calendar Year

EDUCATION

OTHER PARTY

(If divorce/dissolution, this refers to present spouse; otherwise, this refers to your former spouse/parent)

Residence Address

Address

Total Gross Income Last Calendar Year

Education

MARITAL HISTORY

Is Wife Pregnant?YesNo(Not Applicable for Problem Post Divorce )

CHILDREN BY THIS MARRIAGE

(or former marriage if this matter relates to a previous divorce) (indicate if adopted)

Is adopted

Is adopted

Is adopted

Is adopted

RESIDENCES OF ABOVE CHILDREN FOR LAST FIVE YEARS

HEALTH INSURANCE

ADDITIONAL PRELIMINARY INFORMATION

Have you received or paid spousal support?Yes


Have you consulted any therapists?Yes

Have you previously consulted any attorneys within the last year?Yes