Confidential Client Questionnaire Form

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CONFIDENTIAL CLIENT QUESTIONNAIRE
Today's Date: __________________________ Referred to this office by: ___________________________________
Client Name:___________________________________________________________________________________
Address: ____________________________________________________ County: __________________________
City: ______________________________ State: _________________ Zip: _____________
Social Security Number: ______________________ Date of Birth: _______________________
Age: __________
Phone Numbers: Home ________________________________ Cell _____________________________________
Work _____________________________ Fax _________________________ (Call first? Yes □ No □ )
Marital status: _______________________________________
If married or living together, name of spouse or partner: _________________________________________________
If you have children or stepchildren who live with you, for each child, list the child’s name, date of birth,
relationship, and name of the other parent:
Name
Date of Birth
Child or Stepchild
Other Parent
_____________________
___________
_____________________
_____________________________
_____________________
___________
_____________________
_____________________________
_____________________
___________
_____________________
_____________________________
_____________________
___________
_____________________
_____________________________
If you have children who do not live with you, for each child, list the child’s name, date of birth, name of other parent,
and who has custody/guardianship of the child:
Name
Date of Birth
Name of Other Parent
Custody/Guardianship
_____________________
___________
_____________________
_____________________________
_____________________
___________
_____________________
_____________________________
_____________________
___________
_____________________
_____________________________
_____________________
___________
_____________________
_____________________________
Have you lost your parental rights as to any of the children listed above? Yes □ No □
If you have lost your parental rights, please list the names of the children for which your parental rights have been
terminated:_____________________________________________________________________________________
For any of your children, is the other parent dead, missing, or incarcerated: Yes □ No □
If yes, please give details: _________________________________________________________________________
______________________________________________________________________________________________
Are you required to pay child support? Yes □ No □
If you owe child support, for each case, list the county where the case was filed, the case number, and the amount
you need to pay:
County
Case No.
Weekly Payment Amount
Are You Current?
Yes □ No □
__________________
____________________
_____________________
Yes □ No □
__________________
____________________
_____________________
Yes □ No □
__________________
____________________
_____________________
FOR ATTORNEY USE ONLY:
New Client Letter Sent:
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