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

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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:

_______________________________          ___________________________________

_______________________________          ___________________________________

_______________________________          ___________________________________

 

Length of Time at that Address:  _______ years       _______ years

 

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

_______________________________          ___________________________________

_______________________________          ___________________________________

_______________________________          ___________________________________

 

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)

_______________________________          ___________________________________

_______________________________          ___________________________________

_______________________________          ___________________________________

_______________________________          ___________________________________

 

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?

_______________      _________      _______________

_______________      _________      _______________

_______________      _________      _______________

_______________      _________      _______________

_______________      _________      _______________

 

Children from Other Marriages or Relationships

Name                           Date of Birth   Residing with whom?

_______________      _________      _______________

_______________      _________      _______________

_______________      _________      _______________

_______________      _________      _______________

_______________      _________      _______________

 

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

_____________________________________________________________________________

 

Describe the circumstances for which you seek legal representation:

 

______  Neglect and Dependency Petition  ____________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

_____  Termination of Parental Rights  _____________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

_____  Child Abuse Allegations  ___________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

_____  Other  __________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

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

Why or why not?  _______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

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

 

If yes, explain:  _________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

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

Mother:  _______  Father:  _______ 

If yes, explain:  ________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

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

If yes, explain:  _________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

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

If yes, explain:  _________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

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

If yes, explain:  _________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

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:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Questions to Ask My Attorney:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Next Steps
Contact a qualified family law attorney to make sure
your rights are protected.
(e.g., Chicago, IL or 60611)

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