Intake Form Detailed Intake FormPlease enable JavaScript in your browser to complete this form.Your InformationFull Name *FirstMiddleLastMaiden Name Phone *Email *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of BirthState of BirthEmployment InformationEmployerOccupationLength of Employment (In Years)Length of EmploymentLess than 1123456-910+PhoneGross Salary (Yearly) Selected Value: 0 Net Salary (Yearly) Selected Value: 0 Former/ Current Spouse or Opposing Party InformationFull Name *FirstMiddleLastMaiden Name Phone *EmailAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of BirthState of BirthNumber of Previous MarriagesFormer / Current Spouse or Opposing Party Employment InformationEmployerOccupationLength of Employment (In Years)Length of EmploymentLess than 1123456-910+PhoneGross Salary (Yearly) Selected Value: 0 Net Salary (Yearly) Selected Value: 0 Marital InformationDate of MarriagePlace of MarriageWhat number is this marriage?12345Are you and your spouse currently living together?Choose OptionYesNoDo you have an interest in reconciling with your spouse?Choose OptionYesNoTo the best of your knowledge does your spouse want reconciliation?Choose OptionYesNoDescribe the circumstances that caused your separation.Children of MarriageDo you have children from this marriage?Choose OptionNo I do notYes - 1 childYes - 2 childrenYes - 3 childrenYes - 4 childrenYes - 5 childrenChild's NameBirthdateAgeSexChild's genderMaleFemaleChild is living with...Ex: You, Spouse, Grandparents, etc...Second Child's NameBirthdateAgeSexChild's genderMaleFemaleChild is living with... Ex: You, Spouse, Grandparents, etc...Third Child's Name BirthdateAgeSexChild's genderMaleFemaleChild is living with...Ex: You, Spouse, Grandparents, etc...Fourth Child's NameBirthdateAgeSexChild's genderMaleFemaleChild is living with...Ex: You, Spouse, Grandparents, etc...Fifth Child's Name Birthdate AgeSexChild's genderMaleFemaleChild is living with...Ex: You, Spouse, Grandparents, etc...Children of Prior Marriage / RelationshipDo you have children from a prior marriage?Choose OptionNo I do notYes - 1 childYes - 2 childrenYes - 3 childrenYes - 4 childrenNameBirthdateAgeSexChild's genderMaleFemaleSecond Child's NameBirthdateAgeSexChild's genderMaleFemaleThird Child's NameBirthdateAgeSexChild's genderMaleFemaleFourth Child's NameBirthdateAgeSexChild's genderMaleFemaleVehiclesNumber of vehicles between you and your spouse.Choose OptionNone123Type of VehicleLenderTitle Vested InBalance OwedMonthly PaymentVehicle 2 - Type of VehicleLender Title Vested InBalance OwedMonthly PaymentVehicle 3 - Type of VehicleLenderTitle Vested InBalance OwedMonthly PaymentReal Estate1st Mortgage HolderBalance OwedMonthly PaymentProperty AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code2nd Mortgage HolderBalance OwedMonthly PaymentProperty AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRetirement/Whole Life InsuranceI have the following (Check All That Apply)Retirement / 401KWhole Life InsStocks / BondsOtherEstimated total value of all accounts.Whose PropertyChoose OptionMineSpouseBothOther InformationHas your spouse consulted an attorney regarding this matter?Choose OptionNoYesNot SureHave you consulted an attorney regarding this matter?Choose OptionNoYesSpouses Attorney InformationYour Attorney InformationSubmit