Client Intake Form

We are looking forward to working with you. Please fill out the following intake form below. (Click here for a .pdf version that you can print and fill out on your own.) There are four sections total: Client Contact Information, Client Background Information, Spouse's Information and Marriage History. When finished, simply click the "submit" button at the bottom of the form and we will get back to you within 24 hrs.

Note: The fields with a red "*" are required.

Client Contact Information:

*First Name: *Last Name:

Street Address:

City: State: Zip Code:

Check if you can receive mail at this address.

*Phone #1: Home Cell Work

* This phone number is private and I can receive messages at it.

Phone #2: Home Cell Work

This phone number is private and I can receive messages at it.

*Email:

Client Background Information:

Birthday: Month Date Year

Employer:

Occupation: Salary: $ hr year

Spouse's Information:

First Name: Last Name:

Street Address:

City: State: Zip Code:

Employer:

Occupation: Salary: $ hr yr

Marriage History:

Date of Marriage:
Month Date Year

Children of Marriage (leave blank if not applicable):

Child #1:
Name Birthdate Gender? M F
Birth City Birth State

Child #2:
Name Birthdate Gender? M F
Birth City Birth State

Child #3:
Name Birthdate Gender? M F
Birth City Birth State

Check here if you have more than three children through this marriage.

Date of Separation (if applicable):
Month Date Year

Level of Conflict (10 being the worst):

1 2 3 4 5 6 7 8 9 10

Any violence? || Have the Police been called?

Have any restraining orders been filed?

Do you expect custody and visitation issues to be disputed?

Be sure to click on the 'Submit' button when you are done. Thank you!