CLIENT INTERVIEW SHEET
Date: ______
Please complete thisquestionnaire. If you will 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 family law problem. All information will be held in strict confidence.
1. Please give your date, place of birth and Social Security number.
a.Name:______
b.Date of birth:______
e.Place of birth:______
d.Social Security Number: ______
e.Driver's License Number: ______
2. Where are you living now?
a.Address: ______
b.City, State, Zip: ______
3. Please give your residence and cell telephone number:
4. Please complete the following concerning your employment.
a.Employer:______
b. Job Title: ______
c.Street Address: ______
d.City, State, Zip: ______
e.Telephone number (resident/cell/work): ______
f. Gross per month or annually: $______
g.Length of employment: ______
h.Education: ______
5. Please give your spouse's fullname, date and place of birth, and social Security number.
a.Name:______
b. Date of birth:______
c. Place of birth;______
d. Social security Number:______
e. Driver's License Number:______
6. Where is your spouse living and what is your-spouse's telephone number?
a.Address:
b.City, State, Zip:______
c. Residence telephone number:______
7. Complete the following concerning your• spouse's employment.
a. Employer:______
b. Job Title:______
c. Street Address:______
d. City, State, Zip:______
e. Telephone number:______
f. Spouse's gross salary per month or annually: $______
g. Length of spouse's employment: ______
h. Education of spouse:______
8. Please give the date and place of your marriage.
Date: ______
City, State:______
9. Please give full name, date and place of birth, sex, Social Security number, and driver's license number of each child of this marriage.
A.NAME:______
SEX:
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER: ______
B. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE!______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER: ______
C. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:
SOCIAL SECURITY NUMBER:______
10. Are you now separated from your spouse?______
If so, .give date of separation.______
11. Have you seen any marriage counselor? If so, give name______
12. What is your religious preference?______
What is your spouse's religious preference?______
13. Check as appropriate if your marital difficulties involve any of the following:
Drugs/alcohol [ ]
Physical violence [ ]
Sexual disappointment [ ]
Religion [ ]
Sexual infidelity [ ]
Incompatibility [ ]
Financial disputes [ ]
Other:______
14. Will there be a dispute over custody of the children?______
If not,custody will be with whom?
______
15. Where are the children living at this time? ______
16. List all property (other than furniture and clothing) owned by the children.______
17. How long have you lived in Texas?______
18. What county do you reside in? ______
19. How long have you lived in Texas?______
20. How long have you resided in that county? ______
Have you or your spouse ever filed for a divorce? ______
If so, when and where?______
21. Does your spouse now have an attorney?______
If so, who?
22. Have you been married before? ______
If so, how many times?______
Do you have children by a previous marriage?______
If so, give full name, date and place of birth, and sex of each child of your previous marriages.
A. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER:______
B. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER.______
C. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER:______
D. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER.______
With whom do these children reside:______
23. Do you pay/receive child support?
If so, how much? $______per______
24. Has your spouse been married before?______
If so, how many times?______
Does your spouse have children by a previous marriage?
If so, give full name, date and place of birth, and sex of each child of spouse's previous marriage
A. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER:______
B. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER.______
C. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER:______
D. NAME:______
SEX:______
BIRTHPLACE:______
BIRTH DATE:______
DRIVER'S LICENSE NO:______STATE:______
SOCIAL SECURITY NUMBER.______
With whom do these children reside? ______
25. Does your spouse pay/receive child support?______
If so, how much? $______per______
26. If a divorce is granted, should the wife's maiden or prior name be-restore?
If so, what name should be used?
Summary Of Property
Real Estate
1.Address:______
Mortgage company:______
Estimated fair market value: $______
Year bought:______
Mortgage balance: $______
Monthly payments: $______
2.Address:______
Mortgage company:______
Estimated fair market value: $______
Year bought:______
Mortgage balance: $______
Monthly payments: $______
3.Address:______
Mortgage company:______
Estimated fair market value: $______
Year bought:______
Mortgage balance: $______
Monthly payments: $______
Motor Vehicle, Boats, Airplanes, Cycles, Trailers:
1. Year:______Model:______
Who drives?______
Financed with:______
2. Year:______Model:______
Who drives?______
Financed with:______
3. Year:______Model:______
Who drives?______
Financed with:______
4. Year:______Model:______
Who drives?______
Financed with:______
5. Year:______Model:______
Who drives?______
Financed with:______
Bank Account, Savings Accounts, CDs’, Credit Union, Savings
1. Name of bank:______
Account name:______
Amount on deposit: $______
Names on withdrawal card: ______
2. Name of bank:______
Account name:______
Amount on deposit: $______
Names on withdrawal card: ______
3. Name of bank:______
Account name:______
Amount on deposit: $______
Names on withdrawal card: ______
4. Name of bank:______
Account name:______
Amount on deposit: $______
Names on withdrawal card: ______
Life Insurance
1. Name of company:______
Insuring Life of:______
2. Name of company:______
Insuring life of: ______
3. Name of company:______
Insuring Life of:______
Stocks, Mutual Funds:
1. Name of stock:______
Estimated amount invested : ______
2. Name of stock:______
Estimated amount invested: ______
3. Name of stock:______
Estimated amount invested: ______
4. Name of stock:______
Estimated amount invested: $ ______
Stocks, Mutual Funds
1. Do you participate in any retirement plan? ______
Does your spouse participate in any plan?______
2. Do you participate in any company savings plan? ______
If so, how much do you have in that savings plan? $______
3. Does your spouse participate in any company savings plan? ____
If so, how much does your spouse have in that savings plan?
$ ______
4. Does anyone owe you or your spouse any money? ______
If so, how much? $______
owed by whom?______
5. Are you involved in any lawsuits?______
If so, explain.______
______
6. Do you own any livestock or mineral interests? ______
7. Do you belong to any clubs with an equity interest? ______
If so, where? ______
Debts: (other than house and/or automobiles)
1. ______$______
2. ______$______
3. ______$______
4. ______$______
5. ______$______
6. ______$______
7. ______$______
8. ______$______
9. ______$______
10. ______$______
Income Tax
Have you filed for all previous years?______
Prepared by whom?______
Refund received?______
If so, how much? $ ______
Separate Property
1. Do you own any separate property (property owned before marriage or property received during marriage by gift or inheritance)? ______
if so, detail your separate property.______
______
______
- Does your spouse. own any separate property? ______
If so, detail-the separate property:______
______
______
Last Will and Testament
1. Do you have a will? ______
If so, prepared by whom?______
- Does your spouse have a will? ______
If so, prepared by whom? ______
At what address do you wish to -receive mail from this office? ______
______
Referral
Who referred you to this office? ______
I understand that there will be an initial $______Consultation Fee regardless of whether I decide to take any legal action or not.
______Client Signature