Divorce Intake Form Attorney Michael Ephraim

Client Information

Client's First Name:*

Client's Middle Name:

Client's Last Name:*

(example: Smith Jr)

Gender:

Male
Female

Client's Full MAIDEN Name:

Name Change

Are you requesting a name change?

Yes
No

What would you like your name changed to?

First Last

Marriage Details

Date of Marriage:

Place of Marriage:

Date of Separation:

Do you already have a signed Separation and Property Settlement Agreement?

Yes
No

Phone

Phone #:*

Primary Phone Numer

Phone #2:

Phone #3:

Email

Email Address:*

Primary Email Address

Other Email:

Physical Address

Street Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address

(if different from Physical Address)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Residency Status

Are you currently a Virginia resident?

Yes. I have lived in Virginia continuously for at least one year.
Yes. I have lived in Virginia continuously for less than one year.
No
Yes. I am on active duty in the U.S. Armed Forces and have been stationed in Virginia.

I have lived in Virginia Since:

(less than 1 year residency)

I have been stationed in Virginia since:

(stationed in Virginia)

Spouse Residency Status

Is your spouse currently a Virginia resident?

Yes. My spouse has lived in Virginia continuously for at least one year.
Yes. My spouse has lived in Virginia continuously for less than one year.
No
Yes. My spouse is on active duty in the U.S. Armed Forces and has been stationed in Virginia.

My spouse has lived in Virginia since:

(resident less than 1 year)

My spouse has been stationed in Virginia since:

(stationed in Virginia)

Spouse Information

Will your spouse sign a document agreeing to the divorce?

Yes
No
Unsure
Cannot locate spouse

How do you want your spouse to recieve the documents?

EMAIL the documents to me and I will send/take the documents to my spouse.
I will PICK UP the documents at the office.
MAIL the documents to me and I will send/take them to my spouse.
EMAIL the documents directly to my spouse.
My spouse will PICK UP and sign the documents at the office.
MAIL the documents directly to my spouse.
Not Applicable, I am requesting that the divorce proceed by publication in the newspaper.
Unsure.

Spouse's First Name:

Spouse's Middle Name:

Spouse's Last Name:

(example: Smith Jr)

Spouse's full maiden name (if applicable):

What is your spouse's gender?

Male
Female

Spouse Name Change

Is your spouse requesting a name change?

Yes
No

What does your spouse want to change their name to?

First Last

Spouse's Contact Information

(NOT FILLING IN THE ADDRESS WILL DELAY YOUR CASE. If current address is unknown, what was the last known mailing address?)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Phone #:

Primary Phone Number

Phone #2:

Phone #3:

Email

Email Address:

Primary Email Address:

Other Email:

Children

How many children were born to or adopted by you and your spouse?

(Please include all children regardless of age)

Child One:

First Last

Child One Date of Birth:

Child One is Living With:

First Last

Child Two:

First Last

Child Two Date of Birth:

Child Two is Living With:

First Last

Child Three:

First Last

Child Three Date of Birth:

Child Three if Living With:

First Last

Child Four:

First Last

Child Four Date of Birth:

Child Four is Living With:

First Last

Child Five:

First Last

Child Five Date of Birth:

Child Five is Living With:

First Last

Child Six:

First Last

Child Six Date of Birth:

Child Six is Living With:

First Last

Child Seven:

First Last

Child Seven Date of Birth:

Child Seven is Living With:

First Last

Child Eight:

First Last

Child Eight Date of Birth:

Child Eight is Living With:

First Last

Do you plan to include custody in the divorce or do you have a signed agreement which includes custody?

Yes. I plan to include custody in the divorce.
Yes. Custody is already stated in a signed agreement which I am requesting be incorporated in the divorce decree.
Yes. There is a custody court order currently in effect but I am requesting that the terms of that order be changed.
No. There is a custody court order currently in effect which I am not requesting be changed.
No. There is no provision for custody in a signed agreement and no current court order and I am not requesting that custody be included.

Do you plan to include child support in the divorce or do you have a signed agreement which includes child support?

Yes. I plan to include child support.
Yes. Child support is already stated in a signed agreement which I am requesting be incorporated in the divorce decree.
Yes. There is a child support court order currently in effect but I am requesting that the terms of that order be changed.
No. There is a child support court order currently in effect which I am not requesting be changed.
No. There is no provision for child support in a signed agreement and no current court order and I am not requesting that child support be included.

Financials

Do you and your spouse have any financial assets/property to divide or debts to resolve?

Including houses, cars, bank accounts, personal property, credit cards, etc.

Yes
No

Please detail the assets below:

Are you or your spouse requesting spousal support/alimony?

Yes
No

Please detail the spousal support request:

Do you or your spouse have any pension, retirement plan, 401(k) that will be divided?

Yes
No

Please detail the retirement benefit division request:

United States Armed Services

Are you on active duty in the United States Armed Services?

Yes
No

Is your spouse on active duty in the United States Armed Services?

Yes
No

Status of Divorce

Has a divorce case already been filed in any court by you or your spouse?

Yes
No

Is the divorce case still open?

Yes
No

In which court was the case filed?

Client Demographic Information

Client's Race:

Client's Place of Birth:

Client's Date of Birth:

Client's Education Level:

Highest Level Completed

Client's number of marriages:

Spouse Demographic Information

Spouse's Race:

Spouse's Place of Birth:

Spouse's Date of Birth:

Spouse's Education:

Highest Level Completed

Spouse's number of marriages:

Other Information

Is there any other information that the attorney should know about your situation?

Do you have any questions about the divorce procedure?

Name

This field is for validation purposes and should be left unchanged.