Client Intake Form Custody/Support

Client Intake Form – Custody/Support

Date:______F.C. No. ______of ______

______

First NameLast Name Middle Initial

Address: ______

City: ______State: ______Zip Code:______

County: ______How Long in CurrentCounty:______

Home Phone: ______Work Phone: ______

Cell Phone: ______Please Check Preferred Contact Number

Mailing Address (if different from physical address) ______

______

Social Security Number: ______Date of Birth: ______

Date of Marriage: ______Date of Separation: ______

Location of Marriage: ______

Who may we contact if we cannot get ahold of you: ______

Phone Number: ______

Opposing Party

______

First NameLast Name Middle Initial

Address: ______

City: ______State: ______Zip Code:______

County: ______How Long in CurrentCounty:______

Home Phone: ______Work Phone: ______

Cell Phone: ______Please Check Preferred Contact Number

Mailing Address (if different from physical address) ______

______

Social Security Number: ______Date of Birth: ______

Counsel for Opposing Party: ______

Has either party previously filed a complaint/petition/etc. with the court? Y N

If YES, what was filed and when? ______

Children

Number of children from this relationship? ______

Name: ______DOB: ______SSN: ______M F

Where is/are the child(ren) residing? ______

Addresses where the child(ren) have resided for the past five years:

Dates:With Whom the Child(ren) Lived:Address:

______

Please list any children not of this relationship, their relationhsip to the parties, and their current residence(s):

______

Specify what custody arrangement you believe is appropriate, with a brief explanation of the reasons why:

______

Please list any specific times that you wish to have custody/visitation (i.e. holidays, vacation, birthdays, regularly held family events, etc.):

______

Please list the child(ren)’s present:

Religion: ______

Doctor (name and address): ______

Dentist (name and address): ______

Other Medical (name and address): ______

School(s) (name and address): ______

______

Childcare Provider(s): ______

______

Child(ren)’s Extracurricular Activities: ______

______

Other:

Were you ever married to the opposing party? Y N

If YES, date of divorce ______

Is there a current custody order in place?YN

If YES, please bring a current copy of the current custody order.

If you are unable to locate the current custody order, please briefly describe what the order states:

______

Has paternity been established?YN

Is child support currently being paid?YN

If YES, by whom and how much? ______

If there is a current support order, please bring a current copy of the order.

Is the opposing party currently behind in child support and, if so, by how much?

______

Who carries medcal/dental insurance on child(ren)? ______

Monthly cost of medical/dental insurance? ______

Are there childcare expenses? YN

If YES, how much and paid by whom? ______

Gross monthly income for Mother: ______

Gross monthly income for Father: ______