Intake Form – Secure Intake Form

Affordable Legal Help Intake Form

Client ID (Mandatory to fill): *

Name (Mandatory): *

First

Last

Address (Mandatory): *

Address Line 1

City

State

Zip Code

Email: *

Phone Number: *

Birth Date:

Employment:

If Other Service You Want Please Describe:

If The Services You Are Seeking Are For Someone Else Please List Their Name and Your Relationship:

When is a Good Time to Call You:

Please Provide The Last 4 Digits Of Your Drivers License & Issuing State:

Please Provide The Last 4 Digits of Your Social Security Number:

Do You Have a Criminal Record & Does Anyone In Your Household Have A Criminal Record (If Yes Write Persons Name):

Please List All of Your Criminal Convictions, Include Date, And Sentence Served (e.g. Probation, Jail Time, and Prison):

Tell Your Story:

Adverse Party (The Person You Are Taking To Court)

If No Children Apply Insert None:(Mandatory), *

Birth Date:

Name:(Mandatory) *

Address:(Mandatory) *

City, State, and Zip Code:

Phone:

Employers Name and Address:

Job Title & Salary:

List City and State of Where Adverse Party Has Lived For Past (6) Six Consecutive Months:

Does Adverse Party Have a Criminal Record & Anyone In Household Have A Criminal Record (If Yes, Please Provide Persons Name):

Please List All of Adverse Parties Criminal Convictions, Include Date, and Sentence Served (e.g. probation, jail time, prison), Describe What Happened if You Know:

Does Adverse Party Engage in Nefarious Acts (e.g. does illegal drugs, excessive drinking, and excessive gambling) Describe Below:

CHILDREN INFORMATION:

Child 1:

Child 2:

Child 3:

Child 4:

Child 5:

Child 6:

Children's Ages Respectively:

DOBs:

Social Security of All Children's:

List Where The Children Have Lived For The Past Five (5) years

Dates:

City And States where All Children have lived For Past 5 years :

Address where Children's have lived For Past 5 years :

WITH WHOM:

How was Paternity of the Children Determined (DNA Test, signed birth certificate, we were married):

To Which Child Are You Paying Child Support For. Is This A Court Order? If Applicable,Please Inform Us Of The Amount. Are Current Or In The Arrears? If So, How Much Is Owed?

List All Prior Court Cases Involving You, the Adverse Party, and The Children: (List the County, and State of all Prior Court Case, List the Court Case Number):

Please List Current Visitation Orders Or Child Custody Orders:

Divorce

Please Select Below the Services You are seeking:

Date and Place of Marriage:(City, County, and State):

Date of Separation:

Reasons for Separation:

Do You and Your Ex Own Real Property Jointly:

Address of Real Property:

Are There Joint Debts Presently Owed:

Did You and Your Ex Enter Into a Settlement Agreement:

Date and Place of Final Judgment:

Upload all Relevant Documents for your case:

Click or drag files to this area to upload. You can upload up to 99 files.

Please Enter Your Name; This Will Be Considered Your Signature *