Please fill out the following client questionnaire and hit the submit button. If you prefer, you can also download the form and bring it to your first consultation. Client: Opposing Party: Name: Home Address: Street: City: State: Zip: County: Mailing Address (if different): Street: City: State: Zip: County: Contact Information (check preferred method): Home Phone Work Phone Mobile Phone Fax Number Email Addresss Information on Current Marriage: Date of Marriage: City/State of Marriage: Date of Separation:(i.e. last time you had marital relations) Wife's Maiden Name: Maiden Name to be Restored: Yes No How long did/have you lived at the marital home? How long have you lived in that county? How long have you lived in Georgia? Are you interested in reconciliation? Yes No Is your spouse interested in reconciliation? Yes No Have you tried marriage counseling? Yes No If yes, when and with whom? Children of Current Marriage: Name: Date of Birth: Resides With: Are any other children expected? Yes No Do any of the children have special needs? Yes No Please specify any special needs of the children: Where and with whom have the children lived for the past five years? Child's Name: Resides With: Dates: Where do the children attend school? Child's Name: Attends: Monthly Tuition: District: Does anyone other than you or the other parent have any claim with respect to your children for custody, visitation, guardianship or for any other reason? Background Information: Client: Opposing Party: Date of Birth: Place of Birth: Employer: Position/Title: Annual Salary: Annual Bonus: Employed Since: Highest Level of Education Earned: Religious Affiliation (if any): Vehicle(s) Make/Model/Year/Color: Vehicle Registration Name: Information on prior divorce if applicable: Number of prior marriages: Name(s) of prior spouse(s): Date(s) of prior divorce(s): County and State of prior divorce(s): Names/ages of child(ren) from prior marriage(s): Child support order for those child(ren): How much received/paid in child support: Health Information: Are you, your spouse, or any of your children currently receiving any medical or psychological treament? Yes No If yes, please specify who is receiving treatment, who provides the service and what medication or treatments received: Who provides health insurance for the family? Husband Wife Name of Insurance Companies: Health: Vision: Dental: Other: Has your spouse consulted an attorney regarding this matter as far as you know? Yes No If yes, please indicate the attorney's name: Do you have a will? Yes No Is your will in need of revision? Yes No Who are the benficiaries of your will? Name of your accountant: Are there bank accounts, lines of credit, stock and investment accounts or other accounts to which your spouse has access? Yes No If yes, please specify: Does your spouse have in his or her possession credit cards for which you are responsible? Yes No Have you signed anything which may affect the case, including prenuptial or postnuptial agreements, or other documents presented by your spouse? Yes No If yes, please specify: Have you or your spouse sold any real estate property in the last five years? Yes No If yes, please specify: Referral: Who may we thank for referring you to our firm? May we send a thank you letter to the person who referred you to our firm? Yes No Please feel free to write in below any additional information you would like to provide that was not covered by this questionnaire: Please leave this field empty.