Custody Intake Form Date * MM DD YYYY Referred by... Full Legal Name * First Name Last Name Email * Home Phone (###) ### #### Cell Phone (###) ### #### Work Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country How long have you been at this address * Instructions for billing or messages * Other names used Date of Birth MM DD YYYY Age Military Services? Yes No Employer Adverse Party Name First Name Last Name Their Address Address 1 Address 2 City State/Province Zip/Postal Code Country How long have they been at this address? Date of birth MM DD YYYY Age Other names they have used Do they have Military Service? Yes No Their Employer Who is their Attorney? What deadlines are pending? Will they accept service? Yes No Children: Name, DOB, Age (please list one child per line) Thank you!
