Family Law Client Intake

Your Information

Basic contact details

Today's Date *

First Name *

Last Name *

Middle Name

Maiden/Former Name

Date of Birth *

Social Security # (last 4 digits)

For identification purposes only

Contact Information

Street Address *

City *

State *

ZIP *

Is it safe to send mail to this address? *

Yes No

Cell Phone *

Home Phone

Work Phone

Best Time to Call

Is it safe to leave voicemails? *

Yes No

Email Address *

Is it safe to email you? *

Yes No

Employment Information

Employer Name

Job Title/Occupation

How Long at Current Job?

Approximate Gross Monthly Income

$

How Did You Find Us?

How did you hear about us? *

Please be specific (if referred)

Opposing Party Information

Your spouse or the other parent

First Name *

Last Name *

Middle Name

Maiden/Former Name

Date of Birth

SSN (last 4, if known)

Contact Information (if known)

Current Address

Phone Number

Email Address

Employment Information (if known)

Employer Name

Job Title/Occupation

Approximate Gross Monthly Income

$

Attorney Information

Does the other party have an attorney?

Yes No Unknown

Marriage / Relationship Details

Key dates and facts

Are you legally married? *

Yes No (unmarried parents)

Marriage Information

Date of Marriage

Place of Marriage (City, State/Country)

Date of Separation

When you stopped living together as a couple

Length of Marriage

Current Living Situation

Still living together Living separately

Has either party filed for divorce?

Yes No

Prior Legal History

Have you ever been divorced before?

Yes No

Are there any existing court orders regarding custody, support, or protection?

Yes No

Is there a history of domestic violence or protective orders?

Yes No

This information is confidential and helps us understand safety concerns.

Children

Information about minor children involved

Do you have minor children (under 18) with the other party? *

Yes No

Children's Information

Current Custody Arrangement

Who do the children currently live with primarily?

Describe the current parenting schedule (if any):

What custody arrangement are you seeking?

Are there any concerns about the other parent's ability to care for the children?

Yes No

Child Support

Is child support currently being paid?

Yes, I pay Yes, I receive No

Monthly child support amount (if applicable)

$

Tell Us About Your Situation

Please describe why you are seeking legal help today: *

What are your primary goals or concerns?

Is there anything else we should know?

Assets & Property (Optional - Brief Overview)

A detailed financial questionnaire will be provided if needed. For now, just give us a general idea.

Do you own real estate (homes, land)?

Yes No

Are there significant assets to divide (retirement accounts, businesses, investments)?

Yes No Not sure

Are there significant debts?

Yes No

Confidentiality & Fee Agreement

Please review and acknowledge

Confidentiality Statement

I understand that the above information is for the Law Office of Walton, Theiler & Winegarden, LLC and for their office only and will be kept in strict confidence. All information provided in this intake form is protected by attorney-client privilege.

Fee Information

Consultation Fee: Our hourly rate for legal services is $400.00 per hour, plus applicable sales tax (6%).

Additional Time: Time beyond your initial consultation will be billed on an hourly basis.

Credit Card Payments: A 3.2% surcharge applies to all credit card payments.

Additional Costs: You may be billed directly for additional costs such as processor fees, witness fees, deposition fees, filing fees, and other case-related expenses.

I understand and acknowledge the fee structure described above, including the hourly rate, sales tax, credit card surcharge, and potential additional costs. * I understand that the information I have provided is confidential and will be used only for the purpose of evaluating my legal matter. * I certify that all information provided in this form is true and accurate to the best of my knowledge. *

Electronic Signature

Type Your Full Legal Name *

Typing your name constitutes your electronic signature

Today's Date *

Draw Your Signature (Optional)

Your Information

Contact Information

Employment Information

How Did You Find Us?

Opposing Party Information

Contact Information (if known)

Employment Information (if known)

Attorney Information

Marriage / Relationship Details

Marriage Information

Prior Legal History

Children

Children's Information

Current Custody Arrangement

Child Support

Your Case

Tell Us About Your Situation

Assets & Property (Optional - Brief Overview)

Confidentiality & Fee Agreement

Confidentiality Statement

Fee Information

Electronic Signature

Thank You!