Custody Parenting Time Child Support Intake Questionnaire

Custody, Parenting Time, Child Support Intake Questionnaire

Provided by Burroughs Law Office, P.C. (dba) Frugal Legal Services
We look forward to working with you. Please do not present your agreement to the other parent until all of your questions are answered. Also, do not agree to or sign anything without the advice and counsel of a licensed family law attorney. Please call (757) 363-0077 with any questions.
Please enter the complete legal name of the person completing this intake questionnaire in the space provided. (Please: no initials, full names only)

First NameMiddle NameLast NameSuffix
Client Information

The following questions pertain to you (our client).
Enter your complete current legal name in the space provided. (Please: no initials, full names only)

First NameMiddle NameLast NameSuffix
What is your residential address? (This cannot be a PO Box.)

Street Address

Street Address Line 2

CityState

Zip Code
Enter your preferred personal telephone number.
Please enter a valid phone number.
Enter your preferred personal email address.

Confirmation Emailexample@example.com
Which of the following titles best describes you?

ParentMotherFatherOther
What is your date of birth?

MonthDayYear
Enter your Social Security number.
What is your sex?
What are you pronouns?

he/him/hisshe/her/hersthem/their/theirsOther
Are you an active-duty of any branch of the United States armed forces?

YesNo
In which branch of the United States armed forces do you currently serve on active-duty?
What is your Home of Record?
The Other Parent's Information

The following questions pertain to the other parent (also referred to as the opposing party).
Enter the other parent's complete current legal name. (Please: no initials, full names only)

First NameMiddle NameLast NameSuffix
What is the other parent's residential address? (This cannot be a PO Box.)

Street Address

Street Address Line 2

CityState

Zip Code
Enter the other parent's telephone number.
Please enter a valid phone number.
Which of the following titles best describes the other parent?

ParentMotherFatherOther
What is the other parent's date of birth?

MonthDayYear
Enter the other parent's Social Security number.
What is the other parent's sex?
What are the other parent's pronouns?

he/him/hisshe/her/hersthem/their/theirsOther
Is the other parent an active-duty member of any branch of the United States armed forces?*

YesNo
In which branch of the United States armed forces does the other parent currently serve on active-duty?
What is the other parent's Home of Record?
Minor Children
How many minor children do you and the other parent have together (by birth or adoption)?
Will child support be paid by one parent to the other?

Yes. From me to the other parent.Yes. From the other parent to me.We are reserving the issue of child support at this time.
Enter the complete legal name of your first child. (Please: no initials, full names only)

First NameMiddle NameLast NameSuffix
What is your first child's date of birth?

MonthDayYear
Date
What are the last four digits of your first child's Social Security number?
This information is required in cases where child support is being paid by one parent to the other.
Enter the complete legal name of your second child. (Please: no initials, full names only)

First NameMiddle NameLast NameSuffix
What is your second child's date of birth?

MonthDayYear
Date
What are the last four digits of your second child's Social Security number?
This information is required in cases where child support is being paid by one parent to the other.
Enter the complete legal name of your third child. (Please: no initials, full names only)

First NameMiddle NameLast NameSuffix
What is your third child's date of birth?

MonthDayYear
Date
What are the last four digits of your third child's Social Security number?
This information is required in cases where child support is being paid by one parent to the other.
Enter the complete legal name of your fourth child. (Please: no initials, full names only)

First NameMiddle NameLast NameSuffix
What is your fourth child's date of birth?

MonthDayYear
Date
What are the last four digits of your fourth child's Social Security number?
This information is required in cases where child support is being paid by one parent to the other.
Enter the complete legal name of your fifth child. (Please: no initials, full names only)

First NameMiddle NameLast NameSuffix
What is your fifth child's date of birth?

MonthDayYear
Date
What are the last four digits of your fifth child's Social Security number?*
This information is required in cases where child support is being paid by one parent to the other.
Enter the complete legal name of your sixth child. (Please: no initials, full names only)

First NameMiddle NameLast NameSuffix
What is your sixth child's date of birth?

MonthDayYear
Date
What are the last four digits of your sixth child's Social Security number?*
This information is required in cases where child support is being paid by one parent to the other.
Are there any current court orders in place concerning the minor child or children's custody, parenting time, or support.

YesNo
At what address does the minor child currently reside?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom does the minor child reside at the above address? If the minor child resides with more than one person at this address, please select more than one option below.

ClientOther parentOther
If you are currently exercising shared physical custody, please provide the second address for the minor child in the space provided.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom does the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
Please list any other places where and persons with whom the minor child has lived during the last five (5) years in the space provided. If you require additional space, please write the date range and residential address for any other places in the last input block of this intake questionnaire. Please call (757) 363-0077 with any questions.
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
If you were exercising shared physical custody, please provide the second address for the minor child in the space provided.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
Any other address during the last five (5) years?

YesNo
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
If you were exercising shared physical custody, please provide the second address for the minor child in the space provided.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
Any other address during the last five (5) years?

YesNo
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
If you were exercising shared physical custody, please provide the second address for the minor child in the space provided.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
Any other address during the last five (5) years?

YesNo
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
If you were exercising shared physical custody, please provide the second address for the minor child in the space provided.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
Any other address during the last five (5) years?

YesNo
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
If you were exercising shared physical custody, please provide the second address for the minor child in the space provided.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
With whom did the minor child reside during this period of time at the above address? If the minor child resided with more than one person at this address, please select more than one option below.

ClientOther parentOther
Please upload a clean, scanned copy of any orders here.

Cancelof
Are there any pending legal matters in progress concerning the minor child or children's custody, parenting time, or support.

YesNo
Select from one of the following regarding the legal custody of your minor child or children.

I will exercise sole legal custody of the minor child or children.The other parent will exercise sole legal custody of the minor child or children.The other parent and I will share joint legal custody of the minor child or children.The issue of legal custody is already determined by a court order and we are not changing anything at this time.The issue of legal custody is being reserved to the parties.
Select from one of the following regarding the physical custody of your minor child or children.

I will exercise primary physical custody of the minor child or children.The other parent will exercise primary physical custody of the minor child or children.The other parent and I will share joint physical custody of the minor child or children.The issue of physical custody is already determined by a court order and we are not changing anything at this time.The issue of physical custody is being reserved to the parties.
Select from one of the following regarding the parenting time (visitation schedule) of your minor child or children.

The other parent and I agree that I will exercise liberal and reasonable parenting time as agreed between the two of us.The other parent and I agree that we will exercise liberal and reasonable parenting time as agreed between the two of us.We have worked out a set schedule of parenting time.The issue of parenting time is already determined by a court order and we are not changing anything at this time.The issue of parenting time is being reserved to the parties.
Provide the details of your parenting schedule.
Please include as many details as you and the other parent agree to, including but not limited to ordinary parenting time (weekly), summer parenting time, and the division of holidays. Please consider including specifics about the method of exchanging the minor child or children for parenting time, travel-related costs, and set times or locations. Please call (757) 363-0077 with any questions.
Which parent will claim the dependency credits/exemptions for the minor child or children?

I desire that any agreements drafted and any court orders be silent on this matter.I will claim the minor child or children as dependents.The other parent will claim the minor child or children as dependents.We will divide the right to claim the dependency exemption.
In the space provided, detail how the minor child or children will be declared as dependents for tax purposes by you and the other parent.
On which day will child support payments begin?

MonthDayYear
Date
The monthly amount of child support paid is $__________?
Child support will be paid as follows:
Please provide how child support will be paid each month.
(e.g., paid every other week on Friday, paid every week on Friday, etc.)
Which parent is providing health care coverage for the minor child or children?

I am providing health care coverage for the minor child or children.The other parent is providing health care coverage for the minor child or children.We are both providing health care coverage for the minor child or children.Neither of us is providing health care coverage for the minor child or children.
What is your health care policy provider's name?
What is the name of your health care policy?
Who is the policy holder for your health care policy? If this is you, enter your name.
What is the policy number of your health care policy?
What is the other parent's health care policy provider's name?
What is the name of the other parent's health care policy?
Who is the policy holder for the other parent's health care policy? If this is the other parent, enter their name.
What is the policy number of the other parent's health care policy?
Which parent is providing dental care coverage for the minor child or children?

I am providing dental care coverage for the minor child or children.The other parent is providing dental care coverage for the minor child or children.We are both providing dental care coverage for the minor child or children.Neither of us is providing dental care coverage for the minor child or children.
What is your dental care policy provider's name?
What is the name of your dental care policy?
Who is the policy holder for your dental care policy? If this is you, enter your name.
What is the policy number of your dental care policy?
What is the other parent's dental care policy provider's name?
What is the name of the other parent's dental care policy?
Who is the policy holder for the other parent's dental care policy? If this is the other parent, enter their name.
What is the policy number of the other parent's dental care policy?
Which parent is providing vision care coverage for the minor child or children?

I am providing vision care coverage for the minor child or children.The other parent is providing vision care coverage for the minor child or children.We are both providing vision care coverage for the minor child or children.Neither of us is providing vision care coverage for the minor child or children.
What is your vision care policy provider's name?
What is the name of your vision care policy?
Who is the policy holder for your vision care policy? If this is you, enter your name.
What is the policy number of your vision care policy?
What is the other parent's vision care policy provider's name?
What is the name of the other parent's vision care policy?
Who is the policy holder for the other parent's vision care policy? If this is the other parent, enter their name.
What is the policy number of the other parent's vision care policy?
The following information is required in court orders for support.
Select from among the following the most accurate statement regarding your employment.
What is the name of your current employer?
What is the address of your current employer?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your current employer's telephone number?
Please enter a valid phone number.
Do you have a valid state-issued driver's license?

YesNo
Which state issued your current driver's license?
What is your current driver's license number?
Select from among the following the most accurate statement regarding the other parent's employment.
What is the name of the other parent's current employer?
What is the address of the other parent's current employer?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the other parent's current employer's telephone number?
Please enter a valid phone number.
Does the other parent have a valid state-issued driver's license?

YesNo
Which state issued the other parent's current driver's license?
What is the other parent's current driver's license number?
If you have any document that you would like to share with us, please upload it here.

Cancelof
Would you like to upload another document?

YesNo
If you have any document that you would like to share with us, please upload it here.

Cancelof
Would you like to upload another document?

YesNo
If you have any document that you would like to share with us, please upload it here.

Cancelof
If you have any questions or any additional information you'd like to share with us, please use the space below.
Should be Empty:

Custody, Parenting Time, Child Support Intake Questionnaire

Client Information

The Other Parent's Information

Minor Children