Client Intake Form - DeSantis Family Law

Intake Information

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Intake Date

Source

Data Verified

Documents Provided

Pay Stubs Insurance Card Prior Orders Tax Returns Marriage Certificate Birth Certificates

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Drag & drop files here or browse

PDF, Images, Word documents

Client Information

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Identity

First Name

Middle Name

Last Name

Suffix

Maiden/Prior Names

SSN

Date of Birth

Driver's License

Marital Status

Language

Education Level

Other Certifications

Health Status

Health Explanation (if not good)

Contact Information

Street Address

City

County

State

ZIP

Email

Preferred Contact

Cell Phone

Home Phone

Work Phone

Employment

Employment Status

Employer Name

Job Title

Employer Address

City

State

ZIP

Currently Employed

Hire Date

End Date

Annual Salary

Employer Phone

Paychecks Per Year

Gross Income (Monthly)

Work Schedule

Hours/Week

Additional Earnings (Yearly Average)

Overtime (Yearly)

Commissions (Yearly)

Bonuses (Yearly)

Tips (Yearly)

Other Income (Yearly)

Unemployment Comp

Workers' Comp

SS Disability

SS Retirement

Other Retirement

Spousal Support Rcvd

Interest/Dividends

SSI/Public Assist

Child Support Rcvd

Other Income Amt

Other Income Source

Health Insurance

Insurance Provider

Policy Holder Name

Coverage Type

Policy Number

Group Number

Coverage for Children?

Monthly Cost for Children

Insurer Address

Insurer Phone

Attorney

Representation Status

Attorney Name

Firm Name

Firm Address

Attorney Phone

Attorney Email

Safety & Compliance

Confidential Address?

Protection Order?

Safe Contact Restrictions?

OK to Contact Employer?

Other Parent Information

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Identity

First Name

Middle Name

Last Name

Suffix

Aliases/Prior Names

SSN

Date of Birth

Driver's License

Education Level

Other Certifications

Health Status

Health Explanation (if not good)

Contact Information

Street Address

City

County

State

ZIP

Email

Cell Phone

Home Phone

Work Phone

Employment

Employment Status

Employer Name

Job Title

Employer Address

City

State

ZIP

Hire Date

End Date

Annual Salary

Employer Phone

Gross Income (Monthly)

Paychecks Per Year

Work Schedule

Hours/Week

Additional Earnings (Yearly Average)

Overtime (Yearly)

Commissions (Yearly)

Bonuses (Yearly)

Tips (Yearly)

Other Income (Yearly)

Unemployment Comp

Workers' Comp

SS Disability

SS Retirement

Other Retirement

Spousal Support Rcvd

Interest/Dividends

SSI/Public Assist

Child Support Rcvd

Other Income Amt

Other Income Source

Health Insurance

Insurance Provider

Policy Holder Name

Coverage Type

Policy Number

Group Number

Coverage for Children?

Monthly Cost for Children

Insurer Address

Insurer Phone

Attorney

Representation Status

Attorney Name

Firm Name

Firm Address

Attorney Phone

Attorney Email

Children

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Case Information

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Court Type

Order Type

County

Judge

Case Number

File Number

CSEA Number

Date of Existing Order

Marriage Date

Separation Date

Client Role (Support)

Client Role (Case)

Distance Between Homes

Children's School District

Childcare

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Provider Name

Provider Address

Work-Related?

Weekly Cost

Schedule

Monthly Expenses (Client)

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A. Housing Expenses

Rent/First Mortgage

Second Mortgage

Real Estate Taxes

Homeowner Insurance

HOA Fee

Electric

Gas/Fuel

Water/Sewer

Phone/Cell

Trash

Cable/TV

Internet

Cleaning

Lawn/Snow

Other

Other Desc

B. Other Living Expenses

Groceries

Restaurant

Vehicle Loan

Vehicle Maint.

Gasoline

Parking/Transit

Clothing

Dry Cleaning

Hair/Nail

Personal Other

Other

Other Desc

C. Child-Related Expenses

Childcare (Work)

Childcare (Other)

Travel Cost

School Tuition

School Lunches

School Supplies

Activities

Kids Clothing

Allowances

Special Needs

Other

Other Desc

D. Insurance Premiums

Life

Auto

Health

Disability

Other

Other Desc

E. Work & Education Expenses

Work Mandatory

Add'l Taxes

Tuition

Books/Fees

College Loan

Other

F. Health Care Expenses (not covered by insurance)

Physicians

Dentists

Optometrists

Prescriptions

Mental Health

Other

G. Miscellaneous Expenses

Other Kids Oblig.

Other Kids CS

Adult Dependents

Spousal Support

Subscriptions

Charitable

Memberships

Travel/Vacation

Pets

Gifts

Attorney Fees

Other

H. Installment Payments

Creditor

Purpose

Balance Due

Monthly Payment

Creditor

Purpose

Balance Due

Monthly Payment

Creditor

Purpose

Balance Due

Monthly Payment

Property & Debt

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Secured Debts

Unsecured Debts

Finish Intake

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