Interview Date:_________________________

Conflicts_____

Date Retained:__________________________

DIVORCE INTAKE SHEET

I.

CLIENT INFORMATION

Date: _______________
Name: _________________________________________
Last

First

Middle

DOB: _____ Sex: M__ F__

Maiden

Name that you prefer to be called: ___________________________________________

Place of birth: ____________________________________________________________
City

County

State

Country

Social Security No: ____________________ Drivers License No: _________________

Address: __________________________________________ Apt. # _______________
City: ____________________ County: ____________ State: ____ Zip:____________
Home Phone: __________________________ Work Phone _______________________
Email Address: _________________________________ Mobile Phone _____________

___ DO NOT send any correspondence to my home address. Instead,

please send correspondence to my attention at: ___________________
_________________________________________________
___ DO NOT call my home number. Instead, please call my cell phone
or leave a message for me at _______________________
___ I authorize emails concerning my case

Place of Employment: _____________________________________________________

Address of Employment: __________________________________________________
Spouses Name: _________________________________________________________
Spouses Attorney: _______________________________________________________
PERSON FINANCIALLY RESPONSIBLE: ______________________ DOB _______
Address: ________________________________________________________________
Wk Phone: _______________ Hm Phone: ________________ Cell Phone: __________
Social Security Number: _________________ Drivers License No: _________________

EMERGENCY CONTACT INFORMATION:

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Name:
Address:
Wk Phone:
Hm Phone:

_____________________ Relationship: ____________________

_________________________________
_________________________________
_________________________________
_________________________________

Date & City of Marriage:

________________________________________

Date & City of Separation: ________________________________________

II.

OPPOSING PARTY INFORMATION

Full Name:
Address:

________________________
________________________
________________________
Home Phone: ________________________
Mobile Phone:________________________

Maiden Name: ________________

U.S. Citizen? ________________

How long in County? __________________

Social Security No. __________________
Drivers License No. __________________
Date of Birth ________________________
Place of Birth ________________________
Employer:
Address:

________________________
________________________
________________________
Work Phone: ________________________
Gross Monthly Pay: ____________________
Pd: Weekly___ Bi-Weekly___ Semi-Monthly___ Monthly ___
III.

CHILDREN

Where do the children reside? _________________ With whom? __________________

Who presently provides health insurance for the child(ren)? ______________

Monthly cost: $_____________ Name of Policy: ________________________
Policy Number: _____________________________
1. Full Name: ______________________________________________ Age: _______
First

Sex: ______

Middle

Last

Social Security No: ______________ Date of Birth: __________

Place of birth: _____________________________________________________

City

County

State

Special Needs: Yes or No, If Yes, please describe ______________________________

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III.

CHILDREN (continued)

2. Full Name: ______________________________________________ Age: _______

First

Sex: ______

Middle

Last

Social Security No: ______________ Date of Birth: __________

Place of birth: _____________________________________________________

City

County

State

Special Needs: Yes or No, If Yes, please describe ______________________________

3. Full Name: ______________________________________________ Age: _______

First

Sex: ______

Middle

Last

Social Security No: ______________ Date of Birth: __________

Place of birth: _____________________________________________________

City

County

State

Special Needs: Yes or No, If Yes, please describe ______________________________

4. Full Name: ______________________________________________ Age: _______

First

Sex: ______

Middle

Last

Social Security No: ______________ Date of Birth: __________

Place of birth: _____________________________________________________

City

County

State

Special Needs: Yes or No, If Yes, please describe ___________________________

IV.
DEBTS OF PARTIES
VEHICLES:
Yours: ________________________________________________________________
Year

Make

Model

Vehicle Identification No

Spouse: _______________________________________________________________
Year

Make

Model

Vehicle Identification No

Other: _________________________________________________________________
Year

Make

Model

Vehicle Identification No

(If there are more vehicles, please list on a separate sheet)

Other Debts: (loans, credit cards, mortgages, etc.)
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

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V.

PROPERTY OF PARTIES

Is your property already divided by agreement?

_________________

Are you buying or do you own a house?

_________________

Does either party have retirement benefits/stocks of any kind?

If yes, please specify by acct name, number and balance:
______________________________________________________
______________________________________________________
______________________________________________________
(If there is other relevant property, please list on a separate sheet)
VI.

NAME CHANGE REQUEST

Are you requesting the Court to grant a name change?

YES or NO

New Full Name Requested: ________________________________________________

First

VII. OTHER INFORMATION

Does your case involve allegations of:

Middle

Physical Violence
Criminal Record
Excessive Alcohol Use
Adultery
Use of Illegal Drugs
Child Abuse
Financial Problems
Computer Abuse

Last

___________
___________
___________
___________
___________
___________
___________
___________

If physical violence, has a Protective Order ever been issued?

YES or NO
If so, please give details: ___________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Have you ever been charged with any crime other than traffic tickets?
YES or NO
If yes, please give details:__________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Has your spouse ever been charged with any crime other than traffic tickets? YES or NO
If yes, please give details:__________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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Are there any other circumstances which may be a factor in your case?
If yes, please give details:__________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Have you been involved with any Family Law proceeding with any Court or the Attorney
Generals office? If so, please explain fully when, where, and why.
_______________________________________________________________________
_______________________________________________________________________
Have you ever filed Bankruptcy? If so, please explain where, when, and the disposition.
_______________________________________________________________________
Have you or anyone associated with this case been the subject of a:
a)
Protective Order
b)
Restraining Order
c)
Child Protective Services Investigation
d)
Mental Health Professional Treatment
e)
Questionable Paternity Status
f)
Substance Abuse Treatment
g)
Welfare of Aid to Families with Dependent Children
h)
Common-law or Informal Marriage
i)
Termination of Parental Rights
j)
Prenuptial Agreement or Partitioning Agreement
k)
Personal Injury Lawsuits
If so, please explain:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
What, if any allegations against you do you anticipate your spouse will raise? (whether or
not they have any merit)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Are there any other circumstances that you believe that we should be aware of regarding
your situation?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
What legal action(s) have you been involved in previously, if any?
_______________________________________________________________________
_______________________________________________________________________
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Do you or your spouse have accounts on any social networking sites such as Facebook,
MySpace, Twitter, Match.com, or any other social/matchmaking/dating on-line services?
___Yes ___No
If Yes, please list:
_______________________________________________________________________
_______________________________________________________________________
How were you referred to us?
______Website
______Phone book: Name of book: ______________
______Friend (Name:___________________________
______Other (Specify:__________________________
What are your goals and expectations in this matter?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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