Intake Form: For Parents Seeking Legal Representation on Their Own Behalf

If you are facing charges of mistreating your child, it is imperative that you seek competent legal counsel. Any time the potential loss of parental rights is implicated, experienced legal representation is of the utmost importance. By completing the following form, you will give your lawyer the basic information from which to start formulating your defense. If you are married, both parents can complete the relevant portions of the same form. If you are not married, or if the other parent is not involved in the matter, complete just those portions that apply to you.

 

Intake Form: For Parents Seeking Legal Representation on Their Own Behalf

 

MOTHER FATHER

 

Name: ________________________________ ____________________________________

 

Date of Birth: __________________________ ____________________________________

 

Social Security Number: __________________ ____________________________________

 

Address, Including County:

______________________________________________________________________________

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Length of Time at that Address: _______ years _______ years

 

Previous Address(es) (for last 10 years):

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Home Telephone Number: ____________________ ____________________

 

Work Telephone Number: ____________________ ____________________

 

Facsimile Number: ____________________ ____________________

 

E-mail Address: ____________________ ____________________

 

Best Way/Time to Reach: ____________________ ____________________

 

Former Name(s): ____________________ ____________________

____________________ ____________________

 

Employer: ____________________ ____________________

 

Position: ____________________ ____________________

 

Employer’s Address:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Length of Time with Employer: _______ years _______ years

 

Previous Employer(s) (for last 10 years)

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Married _____ Divorced _____ Separated _____ Widowed _____ Single _____

 

Are you currently married to the other parent of the child(ren) that is (are) involved in the present matter? Yes _____ No _____

 

Previous Marriage(s): Yes ____ No ____ Yes ____ No ____

 

Ended by: Ended by:

 

Death ____ Divorce ____ Date _______ Death ____ Divorce ____ Date _______

 

Death ____ Divorce ____ Date _______ Death ____ Divorce ____ Date _______

 

Children of Current Marriage

Name Date of Birth Residing with whom?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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Children from Other Marriages or Relationships

Name Date of Birth Residing with whom?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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Identify the child(ren) to whom this matter relates: ___________________________________

_____________________________________________________________________________

 

Describe the circumstances for which you seek legal representation:

 

______ Neglect and Dependency Petition: ___________________________________________

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_____ Termination of Parental Rights: _____________________________________________

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_____ Child Abuse Allegations: ___________________________________________________

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_____ Other :__________________________________________________________________

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Do you consider the charges that have been raised against you to be true? Mother: _______ Father: _______

Why or why not? _______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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Have you ever been arrested? Mother: _______ Father: _______

 

If yes, explain: _________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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Have you previously been found guilty or did you ever plead guilty to a crime?

Mother: _______ Father: _______

If yes, explain: ________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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Have you ever been incarcerated? Mother: _______ Father: _______

If yes, explain: _________________________________________________________________

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Do you have a history of mental illness? Mother: _______ Father: _______

If yes, explain: _________________________________________________________________

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Do you have a history of alcohol or drug abuse? Mother: ________ Father: ________

If yes, explain: _________________________________________________________________

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List three references who have known you for at least five years. Include a family member, a co-worker, and a social friend or neighbor.

MOTHER

Name Address Relationship How long known?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

FATHER

Name Address Relationship How long known?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Other Important Information:

______________________________________________________________________________

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______________________________________________________________________________

______________________________________________________________________________

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Questions to Ask My Attorney:

______________________________________________________________________________

______________________________________________________________________________

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Next Steps

Contact a qualified family law attorney to make sure your rights are protected.

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