Divorce Intake Form

Client Information

Client's First Name:(Required)

Client's Middle Name:

Client's Last Name:(Required)

(example: Smith Jr)

Choose Divorce Option

Choose either 5 Week Divorce, 2 Week Divorce, or Publication Divorce. No Court Appearance Required For All Options.

Gender:

Male

Female

Client's Full MAIDEN Name:

Name Change

Are you requesting a name change?

Yes

What would you like your name changed to?

In a divorce, you can change your name to your maiden name or a former married name only.

First Middle Last

Do you have former names other than your maiden name?

Yes, 1 former name

Yes, 2 former names

List your former name below

Include: first, middle, and last names; even if one is the same now.

First Middle Last

List your second former name below

Include: first, middle, and last names; even if one is the same now.

First Middle Last

Marriage Details

Date of Marriage:

Place of Marriage:

Date of Separation:

Do you already have a signed Separation and Property Settlement Agreement?

Yes

Phone

Phone #:(Required)

Primary Phone Number

Phone #2:

Phone #3:

Email

Email Address:(Required)

Primary Email Address

Other Email:

Physical Address

Street Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address

(if different from Physical Address)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Residency Status

Are you currently a Virginia resident?

Yes. I have lived in Virginia continuously for at least 1 year.

Yes. I have lived in Virginia continuously for less than 1 year.

Yes. I am on active duty in the U.S. Armed Forces and have been stationed in Virginia for at least 1 year.

Yes. I am on active duty in the U.S. Armed Forces and have been stationed in Virginia for less than 1 year.

I have lived in Virginia Since:

(less than 1 year residency)

I have been stationed in Virginia since:

Spouse Residency Status

Is your spouse currently a Virginia resident?

Yes. My spouse has lived in Virginia continuously for at least one year.

Yes. My spouse has lived in Virginia continuously for less than one year.

Yes. My spouse is on active duty in the U.S. Armed Forces and has been stationed in Virginia for at least one year.

Yes. My spouse is on active duty in the U.S. Armed Forces and has been stationed in Virginia for less than one year.

My spouse has lived in Virginia since:

(resident less than 1 year)

My spouse has been stationed in Virginia since:

Spouse Information

Will your spouse sign a document agreeing to the divorce?

Yes

Unsure

Cannot locate spouse

Spouse's First Name:

Spouse's Middle Name:

Spouse's Last Name:

(example: Smith Jr)

Spouse's full maiden name (if applicable):

What is your spouse's gender?

Male

Female

Spouse Name Change

Is your spouse requesting a name change?

Yes

What does your spouse want to change their name to?

In a divorce, your spouse can change their name to their maiden name or a former married name only.

First Middle Last

Does your spouse have any former names other than their maiden name?

Yes, 1 former name

Yes, 2 former names

List your spouse's former name below

Include all 3: first, middle, and last names; even if one is the same now.

First Middle Last

List your spouse's second former name below

Include all 3: first, middle, and last names; even if one is the same now.

First Middle Last

Spouse's Contact Information

(If current address is unknown, please enter the last known address.)

Spouse's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Spouse's Phone

Spouse's Phone #:

Primary Phone Number

Spouse's Phone #2:

Spouse's Phone #3:

Spouse's Email

Spouse's Email Address:

Primary Email Address:

Spouse's Other Email:

Children

How many children were born to or adopted by you and your spouse?

(Please include all children regardless of age)

Child One:

First Middle Last

Child One Date of Birth:

Child One is Living With:

First Last

Child Two:

First Middle Last

Child Two Date of Birth:

Child Two is Living With:

First Last

Child Three:

First Middle Last

Child Three Date of Birth:

Child Three if Living With:

First Last

Child Four:

First Middle Last

Child Four Date of Birth:

Child Four is Living With:

First Last

Child Five:

First Middle Last

Child Five Date of Birth:

Child Five is Living With:

First Last

Child Six:

First Middle Last

Child Six Date of Birth:

Child Six is Living With:

First Last

Child Seven:

First Middle Last

Child Seven Date of Birth:

Child Seven is Living With:

First Last

Child Eight:

First Middle Last

Child Eight Date of Birth:

Child Eight is Living With:

First Last

Do you plan to include custody in the divorce or do you have a signed agreement which includes custody?

Yes. I plan to include custody in the divorce.

Yes. Custody is already stated in a signed agreement which I am requesting be incorporated in the divorce decree.

Yes. There is a custody court order currently in effect but I am requesting that the terms of that order be changed.

No. There is a custody court order currently in effect which I am not requesting be changed.

No. There is no provision for custody in a signed agreement and no current court order and I am not requesting that custody be included.

Other

Do you plan to include child support in the divorce or do you have a signed agreement which includes child support?

Yes. I plan to include child support.

Yes. Child support is already stated in a signed agreement which I am requesting be incorporated in the divorce decree.

Yes. There is a child support court order currently in effect but I am requesting that the terms of that order be changed.

No. There is a child support court order currently in effect which I am not requesting be changed.

No. There is no provision for child support in a signed agreement and no current court order and I am not requesting that child support be included.

Financials

Do you and your spouse have any financial assets/property to divide or debts to resolve?

Including houses, cars, bank accounts, personal property, credit cards, etc.

Yes

Please detail the assets below:

Are you or your spouse requesting spousal support/alimony?

Yes

Please detail the spousal support request:

Do you or your spouse have any pension, retirement plan, 401(k) that will be divided?

Yes

Please detail the retirement benefit division request:

United States Armed Services

Are you on active duty in the United States Armed Services?

Yes

Is your spouse on active duty in the United States Armed Services?

Yes

Status of Divorce

Has a divorce case already been filed in any court by you or your spouse?

Yes

Is the divorce case still open?

Yes

In which court was the case filed?

Client Demographic Information

Client's Place of Birth:

Client's Date of Birth:

Client's Education Level:

Highest Level Completed

Client's number of marriages:

Spouse Demographic Information

Spouse's Place of Birth:

Spouse's Date of Birth:

Spouse's Education:

Highest Level Completed

Spouse's number of marriages:

Other Information

Is there any other information that the attorney should know about your situation?

Do you have any questions about the divorce procedure?

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