initial client contact & information form - initial... · web viewinitial client contact &...

Initial Client Contact & Information FormFamily Law

Date:

Client’s personal information:

Name/address:

Home phone: Work phone: Cell phone:.

SSN: Date/place of birth: Years in MD:

Education completed: Criminal record?

Employment (where, dates, title, job description, pay):

Driver’s license? Vehicle (description, reliable?)

Substance abuse problems?

Physical or mental health problems?

Child abuse/neglect reports?

OP’s personal information:

Name/address:

Home phone: Work phone: Cell phone:.

SSN: Date/place of birth: Years in MD:

Education completed: Criminal record?

Employment (where, dates, title, job description, pay):

Driver’s license? Vehicle (description, reliable?)

Substance abuse problems?

Physical or mental health problems?

Child abuse/neglect reports?

Relationship of the parties:

Date/place of marriage: Dates and addresses parties lived together

(whether married or not):

Initial Client Contact & Information Form

Prior legal action/orders (divorce, DV, custody, support, etc., description of order, date, jurisdiction)

Is there a written agreement (custody, c/s, alimony, property, etc.):

Is anyone else providing support for children or party?

Does any party or child receive public benefits of any kind (Social Security, SSI, SSDI, TCA, food stamps,

utility assistance, housing subsidy, other?

Children of the parties:

Name Lives With? Date of Birth

Residences of children beginning with present residence and working back:

Dates Address With Whom

FromTo (the present)FromToFromToFromToFromToFromTo

Parties’ other children:

Name & which party’s child Lives With? Date of Birth


Does any child have physical or mental health problems, or behavioral/developmental problems?

Is any child on medication? What, how much, for how long? Does OP agree to the medication? Has any

health care provider or school recommended medication?

Child’s health care providers (primary care, therapists, other):

Primary caregiver before separation? After separation? To what extent is OP involved in parenting, children’s

education, health care?

Where do the parties’ children attend school?

Private? Agreement? Cost? Who pays?

If party pregnant, when is baby due? Father, if not party:

Current custody and visitation arrangement:

Desired custody and visitation arrangement and why in the best interest of the children:

Child support currently from 1 party to the other, how much, how long, is there an order, and date of order?

Health insurance paid by party/for party and/or child, by whom, cost, provided by employer?

Other expenses paid by party/for party and/or child, what, by whom, cost?


Support paid to the other party (either money or payment of expenses), how much, how long, is there an order,

date of order:

Parties’ ability to communicate & cooperate?

Description of homes:

Client OP

Type of residence

# bedrooms

# room

# bathrooms

Yard/property description

Neighborhood/subdivision

Safe & appropriate?

Rent or own

Rent or mortgage

Rent/mortgage current?

Other residents (full name, date of birth, SSN, relationship to client, where sleeps, criminal or drug history

Client’s income information:

Gross income from wages: $

Deductions:


Federal: $

State: $

Medicare: $

FICA: $

Retirement: $

Child support or alimony: $

Union dues: $

Medical insurance: $

Dental insurance: $

Vision insurance: $

Net income from wages: $

Other gross income: $

Deductions:

$

$

$

Other net income: $

Total monthly income: $

OP’s income information:

Gross income from wages: $

Deductions:

Federal: $

State: $

Medicare: $

FICA: $

Retirement: $

Child support or alimony: $

Union dues: $

Medical insurance: $

Dental insurance: $

Vision insurance: $

Net income from wages: $

Other gross income: $

Deductions:

$

$


$

Other net income: $

Total monthly income: $

Property and debt Information (for divorce cases) – Client and OP:

Item FMV? Lien? H,W,J, Client, OP?

Home & other real property (marital or not):

Bank checking/savings:

Stocks/bonds/investments:

Cars/trucks/motorcycles/boats:

Other personal property:

Retirement asset information – both parties:

Description (pension, IRA, 401(k), any deferred benefit plan, other retirement funds)

Vested?

Owner (H,W,J)

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Debt/liabilities information – client and OP:

Creditor (and, if applicable, property secured) Amount Owner (H,W,J)

Mortgage:

Cars/trucks/motorcycles/boats – loans:

Person loans – relatives and friends:


Bank loans:

Unpaid taxes:

Unpaid utilities:

Credit cards:

Client’s monthly expenses for long form financial statement:

For each expense, specify whether children are included. If expense is not monthly, average it over a year and divide by 12.

Expense Amount Expense Amount

Mortgage: $ Homeowner’s insurance: $

Rent: $ Property tax: $

Natural gas: $ Electric: $

Oil – heating and/or cooking: $ Telephone – land line: $

Telephone – cell: $ Trash removal: $

Water/sewer: $ Property repair: $

Lawn care/landscaping: $ Condo/HOA fee: $

Carpet cleaning: $ Domestic assistant: $

Pool maintenance: $ Food: $

Drug store items: $ Household supplies: $

Health insurance (if taken out of paycheck, also note it under “Income”)

$ Therapist or counselor: $

Dentist/Orthodontist: $ Eye doctor: $

“Extraordinary medical” $ Tuition: $

School lunches: $ School books: $

School supplies: $ Extracurricular: $

School uniforms: $ School – room & board: $

Daycare: $ Tuition, etc., for adult: $

Videos, movies: $ Vacations: $

Eating out: $ Cable/Satellite TV: $

Internet: $ Children’s allowance: $

Camp: $ Music/other lessons: $


Cars/trucks/motorcycles/boats payment: $ Cars/trucks/motorcycles/boats payment:

$

Cars/trucks/motorcycles/boats payment: $ Vehicle maintenance, tags, etc. $

Oil/gas: $ Vehicle insurance: $

Parking: $ Public transportation: $

Holiday/birthday gifts: $ Charity: $

Clothing: $ Laundry/dry cleaning: $

Books/magazines/newspapers: $ Hair, Nails, Etc.: $

Alimony (to whom): $ Child support (to whom): $

Pets: $ Life insurance: $

Other (specify): $ $


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