Client Intake Forms Page 1

GENERAL INFORMATION

First Name
Middle Name (spell out)
Last Name
Social Security Number
Date of Birth
Street Address (no PO Box)
City, State and Zip Code
County of Residence
Length of Time at This Address
Home Telephone Number
Other Telephone Number
Email Address
Spouse's First Name
Spouse's Middle Name (spell out)
Spouse's Last Name
Spouse's Social Security Number
Spouse's Date of Birth
Spouse's Address (if living separately)
Spouse's City, State, Zip Code
Mailing Address (if different from above)
Mailing Address City, State and Zip Code
Full Name of Child #1
Age of Child #1
Relationship of Child #1 to you?
Is child #1 living with you?	YES NO If no, who?
Full Name of Child #2
Age of Child #2
Relationship of Child #2 to you?
Is child #2 living with you?	YES NO If no, who?
Full Name of Child #3
Age of Child #3
Relationship of Child #3 to you?
Is child #3 living with you?	YES NO If no, who?
Do you have more than 3 children living with you?	YES NO
If so, provide the same information required above for all additional children in the box at right.
Have you ever filed bankruptcy before?	YES NO If yes, what year?

Have you or your spouse been known by any other name during the past 6 years? (Example: maiden name, last name from previous marriage, legal name change, etc?)
YES NO, If yes, please fill out the information below

Other Name	Dates Used: From To
Other Name	Dates Used: From To