client interview form
DESCRIPTION
Client Interview FormTRANSCRIPT
Client Interview FormANNULMENT OF MARRIAGE
INTERVEWER : ___________________________________
DATE : ___________________________________
Information about the client:
Name:
________________________________________________________LAST FIRST MIDDLE
Maiden Name (if applicable):
________________________________________________________LAST FIRST MIDDLE
Gender : ____________________________________
Nationality :
____________________________________
Date of birth : ____________________________________
Place of birth : ____________________________________
Social Security Number :
____________________________________
Driver's License Number: ___________________________________
Highest Educational Attainment:
_____________________________
Address:
Contact Numbers:
Home : _____________________________________________
Mobile : _____________________________________________
Email Address: ___________________________________________
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Employment:
Employer : _____________________________________________
Job Title : _____________________________________________
Address : _____________________________________________
Telephone number: _______________________________________
Gross salary per month or annually:
__________________________
Length of employment: _____________________________________
Information about the spouse:
Name:
________________________________________________________LAST FIRST MIDDLE
Maiden Name (if applicable): ________________________________________________________
LAST FIRST MIDDLE
Gender : ____________________________________
Nationality :
____________________________________
Date of birth : ____________________________________
Place of birth : ____________________________________
Social Security Number :
____________________________________
Driver's License Number: ___________________________________
Highest Educational Attainment:
_____________________________
Address:
Page 2 of 6
Contact Numbers:
Home : _____________________________________________
Mobile : _____________________________________________
Email Address: ___________________________________________
Employment:
Employer : _____________________________________________
Job Title : _____________________________________________
Address : _____________________________________________
Telephone number: _______________________________________
Gross salary per month or annually:
__________________________
Length of employment: _____________________________________
Information about the Marriage:
Date of Marriage :
_________________________________________
Place of Marriage: _________________________________________
Was the wedding a civil ceremony or religious ceremony:
_________
Date you stopped living together:
____________________________
Address at which you last lived together:
Do you have a written legal separation agreement?
______________
If so, give date of agreement: _______________________________
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Check as appropriate if your marital difficulties involve any
of the following:
Drugs/alcohol [_____] Physical violence [_____]
Sexual disappointment [_____] Religion
[_____]
Sexual infidelity [_____] Incompatibility
[_____]
Financial disputes [_____]
Other [_____] Please specify:
Information about Children:
Name of Child 1 :
____________________________________
Gender : ____________________________________
Birth date : ____________________________________
Birthplace : ____________________________________
Address where child presently resides:
Name of Child 2 :
____________________________________
Gender : ____________________________________
Birthdate : ____________________________________
Birthplace : ____________________________________
Address where child presently resides:
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Name of Child 3 :
____________________________________
Gender : ____________________________________
Birthdate : ____________________________________
Birthplace : ____________________________________
Address where child presently resides:
Will there be a dispute over custody of the children?
YES [_____] NO [_____]
If not, custody will be with whom?
____________________________
INFORMATION CONCERNING PETITIONER’S
CHARACTER REFERENCES:
1. Name :
_________________________________________
Address : _________________________________________
Contact Number: _____________________________________
2. Name :
_________________________________________
Address : _________________________________________
Contact Number: _____________________________________
3. Name :
_________________________________________
Address : _________________________________________
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Contact Number: _____________________________________
__________________________Client’s Name and Signature
__________________________Interviewer’s Name and Signature
Page 6 of 6