Custody Intake Form

Contact Information

Date:

Husband’s Legal Name

Wife’s Legal Name (Please list wife’s name as it should appear on legal documents & vital record forms)

Wife’s Maiden Name

Husband’s Date of Birth

Place

Wife’s Date of Birth

Place

Marriage Date

City

State

Home Address

City

State

Zip

Country

Home Phone

Fax

Who should we call first? Husband Wife

Cell (his)

Cell (hers)

Business (his)

Business (hers)

Email (his)

Please enter a valid email address.

Email (hers)

Please enter a valid email address.

Children

Name

Date of Birth

Race

Relationship

Name

Date of Birth

Race

Relationship

Name

Date of Birth

Race

Relationship

Name

Date of Birth

Race

Relationship

If more than 4, please list under additional notes section at the end of this form)

Additional Client Information

Please list any additional languages that you speak:

Have either of you ever been convicted of a crime?
Yes No

If so, for what were you convicted?

Has there been any record of child abuse in your history?
Yes No

? If so, in what state were you accused?

Information of Child(ren) to be Adopted

Child 1: Full Birth Name

Date of Birth

Gender

Race

Place of Birth

Hospital Address

Hospital City

State

Zip

Country

Date of Placement

City

State

Guardianship Papers?

Child 2: Full Birth Name

Date of Birth

Gender

Race

Place of Birth

Hospital Address

Hospital City

State

Zip

Country

Date of Placement

City

State

Guardianship Papers?

Custody Information

What is the relationship of the Birth Mother and/or Birth Father to you?

What kind of relationship do the child(ren) have with the birth mother/birth father currently?

How did you gain custody of the child(ren)

Have you retained any other legal assistance in this matter?

Birth Mother Information

Birth Mother’s Legal Name

Birth Mother’s Maiden Name

Were you married to the child’s biological father?

Phone Number

Date of Birth

Social Security Number

Race

Last Known Address

City

State

Zip

Amount of visitation in the last 3 years:

Amount of child support paid in the last 3 years

Is birth mother incarcerated?
Yes No

If so, how long?

What facility is she in?

Facility Address

City

State

Zip

Reason for incarceration

Is birth mother in favor of custody?

Birth Father Information

Birth Father’s Legal Name

Married? Yes No

Spouse’s Name

Were you married to the child’s biological mother?

Phone Number

Date of Birth

Social Security Number

Race

Last Known Address

City

State

Zip

Amount of visitation in the last 3 years:

Amount of child support paid in the last 3 years

Is birth Father incarcerated?
Yes No

If so, how long?

What facility is he in?

Facility Address

City

State

Zip

Reason for incarceration

Is birth father in favor of custody?

How did you hear about our office?

Any additional notes?

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For More Than 30 Years

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Assisting Families For More Than 30 Years

Custody Intake Form

Assisting Families
For More Than 30 Years