New Client Intake Questionnaire • Clemens · Warren · Pinkerton

CWPS – New Client Intake

I. CLIENT INFORMATION

Please provide the following information. Fields marked with an asterisk (*) are required.

First Name

Middle Name

Last Name

Maiden Name

Current Residence Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Personal Email Address

Phone Number

Date of Birth

Are You And The Other Party Married?

Yes

Date of Marriage

Date of Separation

Did You and Your Spouse Reside Together Before Marriage?

Yes

Have You Been Married Previously?

Yes

Previous Spouse(s)

Referral Source

II. EMPLOYMENT & EDUCATION INFORMATION

Please provide the following information. Fields marked with an asterisk (*) are required.

Current Employment Status

Employed

Self-Employed

Unemployed

Retired

Employer Name

Job Title / Occupation

Monthly Income

Years of School Completed

Military Service

Yes

Date Service Began

Date Service Ended

Graduate Degrees

College Degrees

Professional Licenses

III. OTHER PARTY INFORMATION

Please provide the following information. Fields marked with an asterisk (*) are required.

Other Party First Name

Other Party Middle Name

Enter the Other Party’s Last Name

Other Party Maiden Name

Other Party Date of Birth

Other Party Current Residence Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Other Party Email Address

Other Party Phone Number

Other Party Current Employment Status

Employed

Self-Employed

Unemployed

Retired

Other Party Employer Name

Other Party Job Title / Occupation

Other Party Monthly Income

Other Party Military Service

Yes

Date Other Party Service Began

Date Other Party Service Ended

IV. CHILDREN

Please provide the following information. Fields marked with an asterisk (*) are required.

Do You and the Other Party Have Children Together?

Yes

Child 1 – Name

Child 1 – Date of Birth

Child 1 – Place of Birth

Child 1 – Gender

Child 2 – Name

Child 2 – Date of Birth

Child 2 – Place of Birth

Child 2 – Gender

Child 3 – Name

Child 3 – Date of Birth

Child 3 – Place of Birth

Child 3 – Gender

Any Other Children?

Yes

Acknowledgment

I understand that submitting this questionnaire does not establish an attorney-client relationship with Clemens Warren Pinkerton Siems and that the firm must complete its conflict review and agree to representation before an attorney-client relationship is formed.