Who referred you to this office?

Maiden name, if applicable:

Citizenship/Immigration Status:

How long have you lived at this address?

How long have you lived in Texas?

How long have you lived in this county?

Who else lives in your household?

Cell phone:

How do you prefer that we contact you?

(e-mail communications may not be confidential)

Facebook:

Instagram:

Twitter:

LinkedIn:

Other:

EMERGENCY CONTACT

Name:

Relationship:

Cell phone:

E-mail:

EMPLOYMENT INFORMATION

Employer:

Job title:

Street address:

Street Address, City, State, Zip

Phone:

May we call you at work?

Yes

No

E-mail:

May we e-mail you at work?

Yes

No

Monthly gross salary:

Annual gross salary:

Length of employment:

Education/training:

5. OPPOSING PARTY

Full name:

Date of birth:

Place of birth:

Social Security number:

Driver’s license number and state:

Maiden name, if applicable:

Citizenship/Immigration Status:

6. OPPOSING PARTY’S CONTACT INFORMATION

Address:

Street, Apt, City, County, State, Zip

Cell phone:

E-mail:

Who else lives in the opposing party’s household?

Facebook:

Instagram:

Twitter:

LinkedIn:

Other:

7. OPPOSING PARTY’S EMPLOYMENT

Employer:

Job title:

Street address:

(Street Address, City, State, Zip)

Phone:

E-mail:

Monthly gross salary:

Annual gross salary:

Length of employment:

Education/training:

8. MARRIAGE AND SEPARATION

Date of marriage:

Place:

Are you now separated? If so, please state date of separation:

Have you seen a marriage counselor?

Yes

If so, please state name:

No

Primary Marital Difficulty

Select an option Substance Abuse/Dependency Sexual Disappointment Sexual Infidelity Financial Disputes Career Decisions Violence (Physical or Threats) Religious Differences Incompatibility Homosexuality Sexually Transmitted Disease(s) Infertility Other

Do your marital issues involve any of the following:

drug/alcoholphysical/emotional abuseconfinement in mental institutionfinancial disputesexual infidelitynon-cohabitationsexual issuesreligious differenceother:

Have you and your spouse attempted reconciliation?

Yes

No

If not, would you like to attempt reconciliation?

What is your religious preference?

What is your spouse’s religious preference?

9. CHILDREN OF THIS MARRIAGE

Name(s) of child(ren) and Information:

1. Jane D. Doe, Female, 01/01/2009; 2. John D. Doe, Male, 01/01/2007; 3. John P. Doe, Male, 02/02/2006, etc.

Name(s) of school(s) child(ren) attends:

The Current grade of each child:

Disability, if any:

10. PRIOR MARRIAGE

Have you or your spouse ever filed for divorce?

Yes

If so, when and where?

No

Have you ever been married before?

Yes

If so, how many times?

No

Has your spouse been married before? If so, how many times?

Yes

If so, how many times?

No

Do you have children from a previous marriage?

Yes

If so, please give the following information for each such child.

(1. Jane D. Doe, Female, 1/12/2009; 2. John E. Doe, Male, 1/12/2008, etc.)

Name, Sex, Date of Birth, Age

No

Where and with whom do these children live?

Do you pay/receive child support?

Yes

If so, how much?

Please designate amount and pay period. For example, monthly vs. biweekly.

No

Does your spouse pay/receive child support?

Yes

If so, how much?

Please designate amount and pay period. For example, monthly vs. biweekly.

No

11. HEALTH INSURANCE INFORMATION

Do you have health insurance?

Yes

No

Does your spouse have health insurance?

Yes

No

Is private health insurance in effect for a child? If so, please give the following information:

Yes

Name of insurance company: Policy number: Party responsible for premium: Monthly cost of premium:

No

Are the children receiving Medicaid benefits under chapter 32, Human Resources Code?

If private health insurance is not in effect for the children, please answer the following questions:

Are the children receiving health benefits coverage under the CHILDREN’S HEALTH INSURANCE PROGRAM under chapter 62, HEALTH AND SAFETY CODE? If so, what is the cost of the premium? Do you have access to private health insurance at a reasonable cost to you?

Please answer, "Yes" or "No."

Does the other parent of your children have access to private health insurance at reasonable cost to them?

Please answer, "Yes" or "No."

Has anyone applied for Medicaid benefits for the children or for coverage for the children under the Children’s Health Insurance Program? Has anyone applied for Medicaid benefits for the children or for coverage for the children under the Children’s Health Insurance Program? If so, who applied? What is the status of the application?

Is the insurance coverage provided through a parent’s employment?

Yes

If so, which parent?

No

Is dental insurance in effect for a child? If so, please give the following information:

Yes

Name of insurance company: Policy number: Party responsible for premium: Monthly cost of premium:

No

Is the dental insurance coverage provided through a parent’s employment?

Yes

If so, which parent?

No

Is vision insurance in effect for a child? If so, please give the following information:

Yes

Name of insurance company: Policy number: Party responsible for premium: Monthly cost of premium:

No

12. GENERAL

Do you and your spouse have a premarital or marital agreement?

Yes

No

Have you or your spouse sued or been sued in the last ten years?

Yes

No

Has a bankruptcy been filed by you or your spouse in the last ten years?

Yes

No

Have you filed an income tax return for each year of your marriage?

Yes

No

Do you have tax problems?

Yes

No

Do you have a tax preparer or accountant who prepares your returns?

Yes

If so, whom?

No

Have you or your spouse ever utilized the services of the Office of the Attorney General?

Yes

No

Have you or your spouse ever sought or been subject to a protective order?

Yes

No

Have you or your spouse ever contacted or been contacted by child protective services?

Yes

No

Have you or your spouse ever been arrested for or convicted of a crime?

Yes

No

Do you own or possess firearms or ammunition?

Yes

If so, please describe the items and state their location.

No

Do you have a license to carry a firearm?

Yes

Issuing State:

No

Are there firearms or ammunition in your spouse’s possession or subject to your spouse’s control?

Yes

If so, please describe the items and state their location.

No

13. ESTATE PLANNING

Do you have a will?

Yes

No

Have you signed a medical or financial power of attorney or other estate planning documents authorizing your spouse to act on your behalf?

Yes

No

Have you executed a transfer on death deed in favor of your spouse? If so, please provide us with a copy of the deed.

Yes

No

14. OTHER INFORMATION

Have you consulted or retained any other attorneys on this matter before coming to this office?

Yes

No

When a divorce is granted, a wife’s maiden name or prior name may be restored. If this is desired, what name should be used?

PRIVACY STATEMENT

FULL NAME:

Please attach any Court Orders related to your case.

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