When a party, the child, or potential party resides outside Texas, other information may be required. See form 2-7 for an additional questionnaire to obtain that information.
Client Name:
Please provide the information requested and return it as soon as possible. It is important that you answer each question candidly and completely so that we can understand and assess your case.
If a question does not apply to your particular situation, please indicate by marking the question “N/A.” If the answer to any question requires more space than has been provided on the form, please complete your answer on a separate sheet. Refer to the question number to which your answer applies and attach your answer to this form.
NOTICE OF CONFIDENTIALITY
The information provided is subject to the attorney-client privilege and attorney work product privileges and will be held in strict confidence. However, if a professional, including an attorney or an employee of an attorney, has cause to believe that a child has been abused or neglected or may be abused or neglected or that a child is a victim of an offense under Tex. Penal Code § 21.11, or that an adult was a victim of abuse or neglect as a child, the professional is required to make disclosure to the appropriate agency. Tex. Fam. Code § 261.101.
1.CLIENT
Full name:
Date of birth: ________________________ Place of birth:
Social Security number (last 3 digits):
Driver’s license number and state (last 3 digits):
Maiden name, if applicable:
2.CONTACT INFORMATION
Current Address:
City: ____________________ County: ______________________ State:
Zip: ____________________ Cell phone:
How long have you lived at this address?
How long have you lived in Texas?
How long have you lived in this county?
Who else lives in your household?
How do you prefer that we contact you?
Address:
Phone: __________________ Fax:
Cell phone:
E-mail:
(e-mail communications may not be confidential)
Do you use social media? If so, indicate which sites are used and the account name:
Facebook: __________________
Instagram: __________________
Twitter: __________________
LinkedIn: __________________
Other: __________________
If you believe that the health, safety, or liberty of you or the children would be jeopardized by disclosure of your address or that of the children, please disclose the reason for that belief.
3.EMPLOYMENT
Employer:
Job title:
Street address:
City, state, zip:
Phone: ____________________________ May we call you at work?
E-mail: ____________________________ May we e-mail you at work?
Monthly gross salary:
Annual gross salary:
Length of employment:
Education/training:
4.OPPOSING PARTY
Full name:
Date of birth: ________________________ Place of birth:
Social Security number (last 3 digits):
Driver’s license number and state (last 3 digits):
Maiden name, if applicable:
5.OPPOSING PARTY’S CONTACT INFORMATION
Address:
City: ____________________ County: ______________________ State:
Zip: ____________________ Cell phone:
E-mail:
Who else lives in the opposing party’s household?
Does the opposing party use social media? If so, indicate which sites are used and the account name:
Facebook: __________________
Instagram: __________________
Twitter: __________________
LinkedIn: __________________
Other: __________________
6.OPPOSING PARTY’S EMPLOYMENT
Employer:
Job title:
Street address:
City, state, zip:
Phone: ____________________________ Fax:
E-mail:
Monthly gross salary:
Annual gross salary:
Length of employment:
Education/training:
7.MARRIAGE AND SEPARATION
Date of marriage: __________________ Place:
Are you now separated? If so, please state date of separation:
Have you seen a marriage counselor?
If so, please state name:
Do your marital issues involve any of the following:
|
____ drug/alcohol |
____ financial dispute |
____ sexual issues |
|
____ physical/emotional abuse |
____ sexual infidelity |
____ religious difference |
|
____ confinement in mental institution____ how long |
____ noncohabitation____ how long |
____ other: |
Have you and your spouse attempted reconciliation?
If not, would you like to attempt reconciliation?
What is your religious preference?
What is your spouse’s religious preference?
8.CHILDREN OF THIS MARRIAGE
Name: ________________________________________ Sex:
Date of birth: ______________ Age: ____ Place of birth (city and state):
Name of school child attends: ______________________________ Grade:
Social Security number (last 3 digits):
Driver’s license number (last 3 digits):
Disability, if any:
Name: ________________________________________ Sex:
Date of birth: ______________ Age: ____ Place of birth (city and state):
Name of school child attends: ______________________________ Grade:
Social Security number (last 3 digits):
Driver’s license number (last 3 digits):
Disability, if any:
Name: ________________________________________ Sex:
Date of birth: ______________ Age: ____ Place of birth (city and state):
Name of school child attends: ______________________________ Grade:
Social Security number (last 3 digits):
Driver’s license number (last 3 digits):
Disability, if any:
Will there be a dispute concerning the children?
If not, with whom will the children primarily reside?
With whom are the children now residing?
Does any child suffer a chronic illness or disability? If so, please describe.
Do the children own significant property (other than furniture, clothing, etc.)?
If a child, a party, or a potential party lives outside Texas, see the attached questionnaire on jurisdictional information for additional questions.
9.PRIOR MARRIAGE
Have you or your spouse ever filed for divorce?
If so, when and where?
Have you ever been married before?
If so, how many times?
Has your spouse been married before? If so, how many times?
Do you have children by a previous marriage?
If so, please give the following information for each such child.
Name:
Sex: __________ Date of birth: __________________ Age:
Place of birth:
Social Security number (last 3 digits):
Driver’s license number and state (last 3 digits):
Disability, if any:
Where and with whom do these children live?
Do you pay/receive child support?
If so, how much? $____________ per
Does your spouse pay/receive child support?
If so, how much? $____________ per
10.HEALTH INSURANCE INFORMATION
Do you have health insurance?
Does your spouse have health insurance?
Is private health insurance in effect for a child? If so, please give the following information:
Name of insurance company:
Policy number:
Party responsible for premium:
Monthly cost of premium:
Is the insurance coverage provided through a parent’s employment?
If so, which parent?
Is dental insurance in effect for a child? If so, please give the following information:
Name of insurance company:
Policy number:
Party responsible for premium:
Monthly cost of premium:
Is the insurance coverage provided through a parent’s employment?
If so, which parent?
Is vision insurance in effect for a child? If so, please give the following information:
Name of insurance company:
Policy number:
Party responsible for premium:
Monthly cost of premium:
If private health insurance is not in effect for the children, please answer the following questions:
Are the children receiving Medicaid benefits under chapter 32, Human Resources Code?
Are the children receiving health benefits coverage under the Children’s Health Insurance Program under chapter 62, Health and Safety Code?
If so, what is the cost of the premium?
Do you have access to private health insurance at reasonable cost to you?
Does the other parent of your children have access to private health insurance at reasonable cost to [him/her]?
Has anyone applied for Medicaid benefits for the children or for coverage for the children under the Children’s Health Insurance Program?
If so, who applied?
What is the status of the application?
11.GENERAL
Do you and your spouse have a premarital or marital agreement?
Have you or your spouse sued or been sued in the last ten years?
Have you filed an income tax return for each year of your marriage?
Do you have tax problems?
Do you have a tax preparer or accountant who prepares your returns?
If so, whom?
Have you or your spouse ever utilized the services of the Office of the Attorney General?
Have you or your spouse ever sought or been subject to a protective order?
Have you or your spouse ever contacted or been contacted by child protective services?
Have you or your spouse ever been arrested for or convicted of a crime?
Do you own or possess firearms or ammunition?
If so, please describe the items and state their location.
Do you have a license to carry a firearm?
Issuing State:
Are there firearms or ammunition in your spouse’s possession or subject to your spouse’s control?
If so, please describe the items and state their location.
12.ESTATE PLANNING
Do you have a will?
Have you signed a medical or financial power of attorney or other estate planning documents authorizing your spouse to act on your behalf?
Have you executed a transfer on death deed in favor of your spouse? If so, please provide us a copy of the deed.
13.OTHER INFORMATION
Have you consulted or retained any other attorneys on this matter before coming to this office?
Is there someone we can contact in an emergency?
Name and Relationship:
Address:
Telephone:
When a divorce is granted, a wife’s maiden name or prior name may be restored. If this is desired, what name should be used?
Who referred you to this office?
Signature of Client
Date