Domestic Client Questionnaire-Potential Termination Of Parental Rights Case
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1
2DOMESTIC CLIENT QUESTIONNAIRE-POTENTIAL TERMINATION OF
PARENTAL RIGHTS CASE
(PLEASE COMPLETE ONLY SECTION I OF THIS FORM PRIOR TO YOUR APPOINTMENT WITH MR. DISBROW)
SECTION I
Today’s Date:
Referred By:
Opposing Counsel, if any:
Your full name___________________________________________________
(First, middle, last name)
Mailing Address:_________________________________________________
__________________________________________________
(
Town, state, zip code)
Phone Number:________________________
_______________________ ________________________
Home
Work
Cell
___________________________________
________________________________________________________________________
Fax
Email address
Drivers License # / State:___________ Social Security #: ____________ Date of Birth:
Your Place of Employment / Address:_______________________________________________________
Your relationship to the children:
Is this matter an EMERGENCY MATTER due to neglect, abuse or violence?
YES
NO
Full Name of Children’s Biological Mother:_________________________________________________
Full Name of Children’s Biological Father:
Mailing address of biological mother:
Mailing address of biological father:
Children’s Full Names:
Date/s of Birth:
Where & with whom is each child residing at this
time?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Biological mother and father married?
YES
NO
If married, please provide the information below:
Date of Marriage:_________________________ Place of Marriage:__________________________________
County / State
Date of Separation: _______________________ Divorce complete?
YES
NO
Date divorce completed and location (county & state):
Is there a current child custody order in effect for the children?
YES
NO
If your answer to the above question is YES, did you bring a copy of the order with you today?
YES
NO
If your answer to the above question is NO, what county and state was the order issued in?
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