PO Box 555
Gorge Ford, NJ 009876
(777) 789-8899 (office)
(789) 786-1177 (fax)
LIGHT LAW FIRM
DIVORCE AND FAMILY MEDIATION CLIENT INTAKE FORM
As a general rule, if we are hired as your attorneys, all the information you give us is treated confidentially. There are situations, however, that may be an exception. For instance, we may be required to disclose any information that is likely to result in bodily injury, death or crime. Nonetheless, should you provide false information with the general intention of disqualifying the firm, then the information you give will be considered non-confidential. Any queries concerning the extent of attorney and client privilege, moreover, are discussed prior to consultation (Kelman Law Firm, 2018).
The following information is necessary in order to properly determine, advise, and handle your case. Print and fill out all the applicable questions. For question that are not applicable, pleas fill this out with N/A. In other words, kindly do not leave any blank spaces. This information will enable us help you (Kelman Law Firm, 2018).
Delegate your assignment to our experts and they will do the rest.
DATE……………………………..
PART A
FULL NAME:…………………………………………………………………………………………………………………………………….
CURRENT MAIDEN NAME (IF APPLICABLE)………………………………………………………………………………………
SPOUSE/OTHER PARENT’S FULL NAME:…………………………………………………………………………………………..
SPOUSE/OTHER PARENT’S MAIDEN NAME (IF APPLICABLE)…………………………………………………………….
HOME (PRESENT) ADDRESS:…………………………………………………………………………………………………………....
HOW LONG AT PRESNT ADDRESS:……………………………………………………………………………………………………
DO YOU OWN OR RENT:…………………………………………………………………………………………………………………..
SPOUSE/OTHER PARENT’S PRESENT ADDRESS:………………………………………………………………………………..
DOES YOUR SPOUSE/OTHER PARENT OWN OR RENT:……………………………………………………………………...
CONFIDENTIAL MAILING (IF DIFFERENT FROM ABOVE:……………………………………………………………………
TELEPHONE No. HOME:……………………………………………….. CELL:………………………………………………………..
WORK:………………………………………………..
SOCIAL SECURITY NUMBER:………………………………………….
EMAIL:…………………………………………………………………….......
DATE OF BIRTH:………………………………………………………………………AGE:………………………………………………..
SPOUSE DATE OF BIRTH:…………………………………………………………AGE:………………………………………………..
DATE OF MARRIAGE:……………………………………………………………….YEARS MARRIED:…………………………..
PLACE MARRIAGE TOOK PLACE (City, County, State)………………………………………………………………………
DATE SEPARATED:…………………………………………………………………..PERIOD SEPARATED:……………………..
PREVIOUS MARRIAGES:…………………………PREVIOUS (MAIDEN) NAMES:………………………………………….
PREVIOUS MARRIAGES ENDED DUE TO (DEATH OR DIVORCE)………………………………………..................
PREVIOUS MARRIAGES FOR OTHER SPOUSE/PARENT:……………………………………………………………………
PREVIOUS MARRIAGES FOR OTHER SPOUSE OR PARENT ENDED DUE TO (DEATH/DIVORCE)…………
No. OF CHILDREN (CURRENT RELATIONSHIP):………………………………………………………………………………….
|
CHILD’S NAME |
AGE |
SCHOOL YEAR |
SCHOOL ATTENDING |
D.O.B |
RESIDES WITH |
FROM PREVIOUS MARRIAGE? |
EDUCATION:………………………………………………………………………………………………………………………………………….
OCCUPATION: ………………………………………………………………………………………………………………………………………. EMPLOYER:…………………………………………………………………………………………………………………………………………….
GROSS INCOME (ANNUAL):……………………………………………………………………………………………………………………
EMPLOYEE BENEFITS:…………………………………………………………………………………………………………………………….
PREVIOUS/OTHER ATTORNEY:………………………………………………………………………………………………………………
YOUR SPOUSE/OTHER PARENT’S ATTORNEY:…………………………………………………………………………………………
PART B
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Is there any order of ‘non-contact’ placed between you and your spouse/other parent? ( )Y ( )N If yes, explain in detail: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....……(Clay Law Firm, 2016) Do you feel threatened in any way by your spouse/other parent? ( ) Y ( )N If yes, explain in detail: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…(Clay Law Firm, 2016) Are there any issues of domestic violence between you and your spouse/ other parent? ( ) Y ( ) N If yes, explain in detail: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...............…………(Clay Law Firm, 2016) Has your spouse/other parent ever: Hit you…... Threatened you...... use physical force against you…. Have the police ever been summoned to your address? ( ) Y ( )N If yes, what for? .........................................................................................................................................................................................................................................................................................................................................................................................................................................................................(Clay Law Firm, 2016) |
PART C
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Are there any pending or previously determined cases in court concerning dissolution of marriage, guardianship, adoption, custody, visitation, maintenance, paternity, neglect, abuse or adult abuse by any of the parties or children involved in this matter? ( ) Y ( ) N If yes, please explain in detail and specify the state and court where and when it occurred including the court case number: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… |
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Did any of the parties in this matter enter into any prenuptial arrangement? ( ) Y ( )N |
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Describe in brief your perspective of the basic matter/issue/problem that resulted in this separation: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… |
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Describe in brief and complaints you believe your spouse/ the other parent would level against you in this matter: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… |
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Does any off the parties involved in this matter have a physical disability of any kind? ( )Y ( )N Would you describe your spouse/other parent as an involved parent? ( )Y ( ) N Explain in detail: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....…(Kelman Law Firm, 2018) |
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Has any of the minor children from the current relationship ever lived with a person other than you or your spouse/other parent? ( )Y ( ) N If yes, provide a list of addresses and dates that occurred within the last 3 years: ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… |
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Have there been any discussions or agreements between you and your spouse/other parent concerning spousal support, custody, or child support? ( ) Y ( )N If yes, please explain: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… |
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Are you or your spouse/other parent expecting another child currently? ( ) Y ( ) N |
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Are there any doubts regarding the paternity of the minor children? ( ) Y ( ) N |
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In regards to children, are there any grandparent or step parent visitation issues? ( )Y ( )N |
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Have you and your spouse/other parent had any discussions regarding the issue of division of assets/debts? ( ) Y ( ) N If yes, explain in detail: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....…(Kelman Law Firm, 2018) Are there any specific assets or debts you believe should belong solely to your spouse/other parent? ( ) Y ( )N If yes, explain in detail: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… |
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What days of the week and time of day are preferable for you to meet? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… |
Permission to include co-mediator (at no extra expense)?.........................................................................
Referred by (Be specific)…………………………………………………………………………………………………………………………
NOTE:
If you are in contact with your spouse/other parent, inform them that we are waiting hear from them before scheduling an appointment (Clay Law Firm, 2016).
If you have provided the other party’s attorney’s name, the firm will try and contact them to schedule an initial meeting sooner (Clay Law Firm, 2016). Family mediation entails a series of meetings with clients to promote communication and decision making in the highlighted issues (Massachusetts Council on Family Mediation, n.d.).
Once the other party has contacted us (or after considerable assessment of details filled in this form), the firm will get in touch with you to schedule our initial meeting.
References
Clay Law Firm. (2016). Mediation Intake Form. Retrieved from http://www.craylawfirm.com/MediationIntakeFormRDG11-20-16.pdf
Kelman Law Firm. (2018). Mediation Intake Sheet. Retrieved from https://static1.squarespace.com/static/5457e5e6e4b0c5d4c473ddb3/t/54b97ea4e4b013117e01ee3d/1421442724825/Mediation+intake+form.pdf
Massachusetts Council on Family Mediation. (n.d.). What is Family Mediation? | Massachusetts Council on Family Mediation. Retrieved from https://mcfm.org/what-family-mediation
