Client Intake Form

Client Intake Form
Date:

Month Day Year
Date
1. Name and Contact Information
Full name: *

First Name Middle Name Last Name
Maiden name (if applicable):
Home address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Additional address (e.g. where are you staying?):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I reside in: *

Ingham County Eaton County Clinton County
Contact Information:
Cell: *
Home:
Work:
Email address:
example@example.com
Are there any locations at which we should not leave a message?
Who should we contact in case of emergency?
Please include name and phone number.

2. Your Personal Information
Date of birth: *

Month Day Year
Date
State of birth: *
Driver's license number:
Driver's license state of issue:
Social Security Number:
Are you a United States citizen? *

Yes No
If not, what is your immigration status?
Date of marriage to other party:

Month Day Year
Date
City and state of marriage:
Number of your previous marriages:
Number of other party's previous marriages:
Are you and the other party currently separated?

Yes No
Date of separation, if separated:

Month Day Year
Date

3. Your Employment Information
Name of company:
Position:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Other Employment:

4. Other Party Involved in this Case
Other party full name: *

First Name Middle Name Last Name
Maiden name (if applicable):
Address of residence: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Other Party Contact Information:
Home:
Cell:
Work:
Email address:
example@example.com
Other Party Personal Information:
Date of birth:

Month Day Year
Date
State of birth:
Driver's license number:
Driver's license state of issue:
Social security number:
Is the other party a United States citizen?

Yes No
If not, what is the other party's immigration status?
Other Party Employment Information:
Name of employer:
Position:
Work address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
May we contact the other party if we need to?

Yes No

5. Children
Does this case involve minor children of you and the other party? *

Yes No
Child 1 (Save this child's information by clicking "Save child/add another child" after adding the child, even if there are no more children to add. Click the same button to add another child):
Residence(s) of the children over the past five years:

6. Referral Information
How did you choose our firm?
Should be Empty: