Intake Divorce Questionnaire Template (Page 2 of 5) in pdf

III.

HISTORY OF THIS MARRIAGE:

Date of Marriage:____________________________ Place:____________________________________

Including this marriage, how many times have you been married? ______________________________

Including this marriage, how many times has your spouse been married? _________________________

Are you and your spouse living together now? ______________________________________________

If not, when did you separate? ___________________________________________________________

Where were you living at the time of your separation? ________________________________________

When was the last time you had sexual relations with your spouse? _____________________________

If separated, and if all your addresses since the separation are not listed above, please list all other

addresses since the separation here:

________________________________________ from __________________ to __________________

Other than what is listed above, have you and your spouse lived together continuously throughout the

marriage? ___________________________________________________________________________

If not, please explain: __________________________________________________________________

____________________________________________________________________________________

IV.

INFORMATION ABOUT YOUR CHILDREN:

Full Name

Date of Birth

Resides with

____________________________________________________________________________________

All addresses the children have lived for the past 5 years and with whom they lived:

Address

Lived with

____________________________________________________________________________________

Do any of your children have any physical or other problems that will be a factor in this case

(i.e., learning disability, physical impairment, etc.)? If so, please explain: ________________________

___________________________________________________________________________________

Do you anticipate a dispute about custody of the children? ____________________________________

____________________________________________________________________________________

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Intake Divorce Questionnaire Template Page 2