Virtulaw Client Intake Form

Client Intake
Information:
Client's Name:*

First NameMiddle NameLast Name
Spouse's Name:*

First NameMiddle NameLast Name
Client's Phone Number*
Client's E-mail*
example@example.com
Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Spouse's Phone Number
Spouse's E-mail
example@example.com
Spouse's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Separation

MonthDayYear
Date of Marriage

MonthDayYear
Would you or your spouse like to restore a former name?

YesNo
Former name (include middle name)
Have you or your spouse lived in California for at least six months?

YesNo
Have you or your spouse lived in this county for the last three months?

YesNo
Party to pay spousal support (Self, Spouse or Waived)

SelfSpouseWaivedOther
Party to pay child Support (Self, Spouse or Other)

SelfSpouseOther
Are you filing for divorce or separation?

DivorceSeparation
Is spouse in active Military?

YesNo
Are you receiving public assistance?

YesNoI plan to apply for public assistance
Is your spouse receiving public assistance?

YesNoOther
Are you and your spouse in agreement on all major issues?

YesNoOther
Child Information:

Children

Will you share joint physical custody?

YesNoOther
Children's residential history for the prior 5 years (include dates & addresses):
State the current custodial arrangements and any preferences or agreements regarding custody of the children.
List any questions you would like to discuss.
Upload Files

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