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Parentage Intake
About You
Your Name
First
Last
Your Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
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Kentucky
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Nevada
New Hampshire
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New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Yes
No
Your Employer
Your Phone
Your Employer Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Yes
No
Their Employer
Their Employer Phone
Their Employer Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Their Type of Work
Their Pay
Marital Information
Ever married to the other parent?
Yes
No
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?
No
Yes
First Child's Name
First
Last
First Child's Sex
Male
Female
First Child's Date of Birth
Month
Day
Year
First Child Lives With
First Child Was...
Born During the Marriage
Born Outside the Marriage
Adopted by the Parties
Second Child's Name
First
Last
Second Child's Sex
Male
Female
Second Child's Date of Birth
Month
Day
Year
Second Child Lives With
Second Child Was...
Born During the Marriage
Born Outside the Marriage
Adopted by the Parties
Third Child's Name
First
Last
Third Child's Sex
Male
Female
Third Child's Date of Birth
Month
Day
Year
Third Child Lives With
Third Child Was...
Born During the Marriage
Born Outside the Marriage
Adopted by the Parties
Fourth Child's Name
First
Last
Fourth Child's Sex
Male
Female
Fourth Child's Date of Birth
Month
Day
Year
Fourth Child Lives With
Fourth Child Was...
Born During the Marriage
Born Outside the Marriage
Adopted by the Parties
Fifth Child's Name
First
Last
Fifth Child's Sex
Male
Female
Fifth Child's Date of Birth
Month
Day
Year
Fifth Child Lives With
Fifth Child Was...
Born During the Marriage
Born Outside the Marriage
Adopted by the Parties
Anything I Should Know About the Kids? Mental, Physical Health Issues? Etc?
Child Support
Is this about child support?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
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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