Intake sheet MISC

Date

MonthDayYear
Date
Type of Case/Matter
Purpose of visit
How did you hear about our services?
Full Name
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Mailing Address (if different than above)
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Age
SSN
Email address
example@example.com
Employer information (this office will never contact you at work without consent)
Annual income
Where can we reach you if it is an urgent matter?
If married, date and place of marriage

MonthDayYear
Date
Other people we can discuss your case with
OPPOSING PARTY:
Full Name
Address
City/State/Zip
Mailing Address (if different than above)
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Age
SSN
Email address
example@example.com
Employer information (this office will never contact your spouse at work without consent)
Annual income
Additional Information: Are you or your spouse in the military?
CHILDREN:
Full Name
Date of Birth

MonthDayYear
Date
Age
SSN
Full Name
Date of Birth

MonthDayYear
Date
Age
SSN
Full Name
Date of Birth

MonthDayYear
Date
Age
SSN
Dates/addresses of whom and where child/children have resided for the past 5 years

MonthDayYear
Date
Dates/addresses of whom and where child/children have resided for the past 5 years

MonthDayYear
Date
Are you requesting joint or sole legal decision-making rights (the legal right and responsibility to make all non-emergency legal decisions for the child including health, education, religious training decisions)?*
Are you requesting shared equal or primary parenting time?*
Detail when and how often your spouse will exercise parenting time
Are you requesting supervised or unsupervised parenting time?*
Do you own real property?
Please provide the address of the real property
Please provide the name(s) of the party(s) on the mortgage?
Please provide the mortgage lender
Please provide the name(s) of the party(s) on the Deed
Please provide your automobile information (year/make/model)
Please provide your automobile loan lender vehicle information
Is this a joint automobile loan?
Please provide your spouse’s automobile information (year/make/model)
Please provide your spouse’s automobile loan lender information
Is this a joint automobile loan?
Do you own joint bank accounts?*
Do you own separate bank accounts?*
Do you want to request your community interest in your spouse’s separate bank account?*
Do you want to waive your community interest in your spouse’s separate bank account?*
Do you participate in a retirement plan?*
Please provide your retirement plan information*
Does your spouse participate in a retirement plan?*
Please provide your spouse’s retirement plan information*
Do you want to waive your community interest in your spouse’s retirement plan?*
Do you want your spouse to waive their community interest in your spouse’s retirement plan?*
Do you have joint credit cards?*
Do you have separate credit cards?*
Do you want to share equally in the joint credit card debt?*
Do you want you and your spouse to be awarded your separate credit card debt?*
Do you have any other joint outstanding loans and debts?*
Please list all joint debts:
Do you or your spouse have separate debts (debt acquired prior to marriage)?*
Do you or your spouse have separate property (property acquired prior to marriage)?*
Do you or your spouse have a drug or alcohol addiction?*
If yes, please detail?*

Other Information:

	Yes	No	Unknown
Is there a bankruptcy pending?
Is there an Order of Protection in place?
Has either party been convicted of/ or is there a pending Domestic Violence case?

Please keep this office advised of changes in address and/or phone number and any lengthy absences which may occur - we MUST be able to reach you at all times.
I authorize emails concerning my case from Villarreal-Orantez, Paralegal Services. I authorize a follow up call regarding my consultation.
SIGNATURE

Clear
ACKNOWLEDGMENT OF NON-REPRESENTATION

Please sign below acknowledging that you understand that Villarreal-Orantez, Paralegal Services, by Amy Villarreal-Orantez is not representing you as an attorney and cannot give legal advice. I understand that the staff and/or owner of Villarreal-Orantez, Paralegal Services is solely in the business of preparing legal documents to assist you through the instant case matter. I understand that there are no attorneys associated with this service. I understand that if I need legal advice that I shall contact an attorney. I agree to hold Villarreal-Orantez, Paralegal Services and Amy Villarreal-Orantez harmless from any claims or losses associated with this matter.
SIGNATURE

Clear
Should be Empty:

OPPOSING PARTY:

CHILDREN: