Divorce Intake Form

Client Data:

 

1. Full legal name: Maiden name:
2. Street Address (City, State, Zip):
3. Home Phone:                                                                         Work Phone:
4. Email Address:
5. Social Security Number:
6. Age: DOB:                                           POB:
7. Education:
8. Date of Marriage: Type of Ceremony:
9. City and State of Marriage:
10. Date Separated:
11. Have Parties Cohabited Since:
12. Immediately preceding today’s date, how long has the client lived continuously in NYS?
13. Previous Marriage:
    1. If yes, how many times:
    2. If yes, how terminated:

 

Spouse Data:

 

14. Full legal name: Maiden name:
15. Street Address (City, State, Zip):
16. Social Security Number:
17. Age: DOB:                                           POB:
18. Education:
19. Military Service:
20. Previous Marriage:
    1. If yes, how many times:
    2. If yes, how terminated:
21. Has spouse lived in NYS for past 12 months:
22. Ethnicity:
23. Do you or your spouse have private health insurance? If so which party has insurance? And who covers who?

 

Children Information:

 

24. Children of the marriage (Give full legal name and date of birth):
25. Who has Custody:
26. Have the Children lived at any other address in the past five years?
    1. If yes, where and with whom (provide present addresses for persons listed):
27. Are the children covered by health insurance:
    1. If yes, under what plan:
28. Are there Orders of Custody and/or Support (please provide copies)? If not do you have Mutual affidavits waiving custody and/or support (again, please provide)?
29. If receiving support, is support being paid through the Support Collection Unit at the Department of Social Services?
30. Has there been any spousal or child abuse:
    1. If yes, is there an existing order of protection?
       1. If yes, please provide copies.