Parentage Intake

About You
Your Name
First Last
Your Address
Street Address Address Line 2 City State ZIP Code
How Long at Your Current Address?
Your Home Phone
Your Cell Phone
Your Work Phone
Your Email
Your Date of Birth
Month
Day
Year
Your Birthplace
Your Race
Your Highest Level of Education
Your Employment
Are You Employed?
Your Employer
Your Phone
Your Employer Address
Street Address Address Line 2 City State ZIP Code
Your Type of Work
Your Pay
About Your Spouse/the Other Parent/Person
Their Name
First Last
Their Address
Street Address Address Line 2 City State ZIP Code
How Long at Their Current Address?
Their Phone
Their Email
Their Date of Birth
Month
Day
Year
Their Birthplace
Their Race
Their Height
Their Weight
Their Hair Color
Their Eye Color
Their Highest Level of Education
Their Employment
Are They Employed?
Their Employer
Their Employer Phone
Their Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Their Type of Work
Their Pay
Marital Information
Ever married to the other parent?
Date of Marriage
Month
Day
Year
Marriage City
Marriage County
Marriage State
Marriage Country
Did you ever live with the other parent? When and why did you stop living with them?
Children
Children?
First Child's Name
First Last
First Child's Sex
First Child's Date of Birth
Month
Day
Year
First Child Lives With
First Child Was...
Second Child's Name
First Last
Second Child's Sex
Second Child's Date of Birth
Month
Day
Year
Second Child Lives With
Second Child Was...
Third Child's Name
First Last
Third Child's Sex
Third Child's Date of Birth
Month
Day
Year
Third Child Lives With
Third Child Was...
Fourth Child's Name
First Last
Fourth Child's Sex
Fourth Child's Date of Birth
Month
Day
Year
Fourth Child Lives With
Fourth Child Was...
Fifth Child's Name
First Last
Fifth Child's Sex
Fifth Child's Date of Birth
Month
Day
Year
Fifth Child Lives With
Fifth Child Was...
Anything I Should Know About the Kids? Mental, Physical Health Issues? Etc?
Child Support
Is this about child support?
Are you/they currently paying child support? How much? How often? Since when? Should it change? Why or why not?
Custody/Allocation of Parental Responsibilities
Is this about custody/allocation of parental responsibilities?
What is the current situation? Do you want it to change? Why do you think it should or should not change?
I do the following for the child(ren)...
- Get dressed in the morning
- Bathes/grooms
- Take care during the day
- Arrange playdates
- Put to bed
- Prepare meals
- Arrange medical/dental visits
- Take to school
- Shop for clothes
- Transport to extracurricular activities
- Participate in extracurricular activities
- Arrange birthday parties
- Help with homework
- Attend parent-teacher conferences
- Act as the person they can turn to
The other parent does the following for the child(ren)...
- Get dressed in the morning
- Bathes/grooms
- Take care during the day
- Arrange playdates
- Put to bed
- Prepare meals
- Arrange medical/dental visits
- Take to school
- Shop for clothes
- Transport to extracurricular activities
- Participate in extracurricular activities
- Arrange birthday parties
- Help with homework
- Attend parent-teacher conferences
- Act as the person they can turn to
Your skeletons
- committed a felony?
- been arrested?
- been in jail or prison?
- used illegal drugs?
- abused prescription drugs?
- abused alcohol?
- DUI or DWI?
- engaged in gambling activities (legal or illegal)?
- engaged in other illegal activities?
- attempted suicide?
- hospitalized for an emotional or psychiatric disorder?
- emotional. or psychiatric condition?
- abused your spouse?
- abused your child?
- suffer from any physical disability that would interfere with being able to care for your child?
- had a sexual relationship during the marriage with someone other than your spouse?
- had a sexual relationship (during or not during the marriage) with someone other than your spouse for which the children were aware?
- engaged in unusual sexual practices?
- had a pregnancy outside of marriage?
- had a venereal disease?
- drunk socially?
If you checked any of the above, please explain...
Other parent's skeletons
- committed a felony?
- been arrested?
- been in jail or prison?
- used illegal drugs?
- abused prescription drugs?
- abused alcohol?
- DUI or DWI?
- engaged in gambling activities (legal or illegal)?
- engaged in other illegal activities?
- attempted suicide?
- hospitalized for an emotional or psychiatric disorder?
- emotional. or psychiatric condition?
- abused your spouse?
- abused your child?
- suffer from any physical disability that would interfere with being able to care for your child?
- had a sexual relationship during the marriage with someone other than your spouse?
- had a sexual relationship (during or not during the marriage) with someone other than your spouse for which the children were aware?
- engaged in unusual sexual practices?
- had a pregnancy outside of marriage?
- had a venereal disease?
- drunk socially?
If you checked any of the above, please explain...
Visitation/Parenting Time
Is this about visitation/parenting time?
Do you/other person currently have visitation? If so, what is it? If not, why not?
Should the current visitation arrangement change? Why or why not? If so, then explain the ideal schedule.
Health Insurance
Do You or Your Spouse/Other Parent Have Health Insurance?
Provider
Whose Policy?
Cost Per Month
What Is Covered?
- Optical
- Dental
- Medical
Who Is Covered?
- Me
- Spouse
- Children
Miscellaneous
Anything Else You Want Me to Know? Any Particular Goals?
Please Attach Any Documents I May Need
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Parentage Intake

About You

Your Employment

About Your Spouse/the Other Parent/Person

Their Employment

Marital Information

Children

Child Support

Custody/Allocation of Parental Responsibilities

Visitation/Parenting Time

Health Insurance

Miscellaneous

Please Attach Any Documents I May Need