Visitation/Custody/Support Intake Form

Visitation/Custody/Support Intake Form
CONFIDENTIALITY: The information you enter in this questionnaire is confidential. The information will not be disclosed to anyone outside of this office, except in the course of rendering legal services on your behalf or as otherwise provided by law.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Source:
Area of Law
CLIENT
Name

First NameLast Name
Address:
City:
State:
Zip:
Mailing Address (if different):
Email Address:
example@example.com
Home Phone:
Cell Phone:
Work Phone:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Soc. Sec. No.:
Name of nearest relative:
Relationship:
Address of nearest relative:
Phone of nearest relative:
County resided in last 90 days:
State resided in last 6 months:
Any pending lawsuits against anyone:
CLIENT EMPLOYMENT INFORMATION
Employer Name:
Employer Address:
City:
State:
Zip:
Date of Hire:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Years of Service:
Occupation:
Hourly or Salary:
Number of Pay Periods:
If hourly, average number of hours per pay period:
If hourly, hourly rate of pay:
Average number of overtime hours per pay period:
Estimated average of net income per pay period:
Estimated average yearly gross income:
Estimated average yearly net income:
Any deduction other than for taxes (health insurance, self-employment expenses, union dues, etc):
Does Client pay or receive child support?
If so, how much?
Are you responsible for any other children not subject to this action?
If so, please list name(s) and date of birth:
OPPOSING PARTY'S PERSONAL INFORMATION
Name

First NameLast Name
Address:
City:
State:
Zip:
Phone:
Email:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Soc. Sec. No.:
Name of opposing parties' attorney:
County resided in last 90 days:
State resided in last 6 months:
Pending lawsuits against anyone:
OPPOSING PARTIES' EMPLOYMENT INFORMATION
Employer Name:
Employer Address:
City:
State:
Zip:
Date of Hire:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Years of Service:
Occupation:
Hourly or Salary:
Number of Pay Periods:
If hourly, average number of hours per pay period:
If hourly, hourly rate of pay:
Average number of overtime hours per pay period:
Estimated average of net income per pay period:
Estimated average yearly gross income:
Estimated average yearly net income:
Any deduction other than for taxes (health insurance, self-employment expenses, union dues, etc):
Does opposing party pay or receive child support?
Is so, how much?
Are they responsible for any other children not subject to this action?
If so, name(s) and date of birth(s)
CHILDREN
Please list children's name(s), date of birth and with whom they reside with:
Is there sole custody or shared parenting?
If sole custody, who is the custodian?
If shared parenting, who is residential parent for school purposes?
CHILD SUPPORT WORKSHEET
Father’s gross annual income:
Mother’s gross annual income:
Other children that you pay support to?
if so, how much?
How many other children (not issue of this marriage) do you have?
Are any of the children employed?
CHILDREN’S HEALTH INSURANCE
Who provides primary coverage:
What is cost per pay period, if any:
Insurance company:
Address:
City, State, Zip:
Phone number:
Policy Number:
Group Number:
Is there secondary coverage available to other party?:
If so, list company name, address, phone number, policy, and group number:
How will out-of-pocket costs be divided?:
How will out-of-pocket costs be divided?:
DEPENDENCY EXEMPTION
Who gets/has exemptions for which children in which years?
VISITATION
Is there a standard shared parenting plan?
Is there be a standard order of visitation?
Is there a customized possession schedule?
Describe possession time of the parents:
Has anyone in the household been convicted of or pled guilty to domestic violence or abuse/neglect of a family member?
PARENTING AFFIDAVIT INFORMATION - this MUST be fully completed if there are minor

children. Where have the children resided for last 5 years and with whom?
Please list where the children have lived for the past 5 years. Include the child's name, dates (from-to), with whom and the address during that time frame:
Please provide a narrative about your case:
Should be Empty:

Visitation/Custody/Support Intake Form

CLIENT

CLIENT EMPLOYMENT INFORMATION

OPPOSING PARTY'S PERSONAL INFORMATION

OPPOSING PARTIES' EMPLOYMENT INFORMATION

CHILDREN

CHILD SUPPORT WORKSHEET

CHILDREN’S HEALTH INSURANCE

DEPENDENCY EXEMPTION

VISITATION