Intake Form - Harrison & Fortier, P.C.

Intake Form

Detailed Intake Form

Your Information

Full Name *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Age

Birth Date

Birthplace

Number of Previous Marriages

Employment Information

Employer

Occupation

Length of Employment (In Years)

Phone

Gross Salary (Yearly)

Selected Value: 0

Net Salary (Yearly)

Selected Value: 0

Spouses Information

Full Name *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Age

Birth Date

Birthplace

Number of Previous Marriages

Spouses Employment Information

Employer

Occupation

Length of Employment (In Years)

Phone

Gross Salary (Yearly)

Selected Value: 0

Net Salary (Yearly)

Selected Value: 0

Marital Information

Date of Marriage

Place of Marriage

What number is this marriage?

Are you and your spouse currently living together?

Do you have an interest in reconciling with your spouse?

To the best of your knowledge does your spouse want reconciliation?

Describe the circumstances that caused your separation.

Children of Marriage

Do you have children from this marriage?

Children of Prior Marriage

Do you have children from a prior marriage?

Vehicles

Number of vehicles between you and your spouse.

Real Estate

1st Mortgage Holder

Balance Owed

Monthly Payment

Property Address

Address Line 1

Address Line 2

City

State

Zip Code

2nd Mortgage Holder

Balance Owed

Monthly Payment

Property Address

Address Line 1

Address Line 2

City

State

Zip Code

Retirement/Whole Life Insurance

I have the following (Check All That Apply)

Retirement / 401K
Whole Life Ins
Stocks / Bonds
Other

Estimated total value of all accounts.

Whose Property

Other Information

Has your spouse consulted an attorney regarding this matter?

Have you consulted an attorney regarding this matter?