# of Previous Marriages of Spouse_________
Do you or your spouse or any of your children have any disabilities/afflictions? ______
If yes, please explain_______________________________________________________
I have been institutionalized in the following hospitals or jails______________________
My spouse has been institutionalized in the following hospitals or
jails____________________________________________________________________
My previous lawyers have been______________________________________________
My spouse’s previous lawyers have been_______________________________________
If now separated, in what county and state did you and your spouse last reside as husband
and wife?________________________________________________________________
If now separated, date of separation__________________________________________
My most important priorities are_____________________________________________
I was referred to Hindson & Melton LLC by___________________________________
4817-8214-5807, v. 1