Custody Intake

Your guide to divorce and family law in Michigan.
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Client Information
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Full Name (First/Middle/Last):AddressCityStateZipPhoneEmail AddressGross Weekly IncomeIncome reported on last year's taxesCounty Residing InLength of Residence in StateDriver's License #Date of BirthPlace of Birth (City, State)Level of Education (Circle One): CopySocial Security NumberMaiden Name

Please list any:
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Criminal ConvictionsAlcohol/Drug AbuseDomestic ViolenceAnything else we should know? Please describe:

Children

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Children Details 1
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Full Name (First/Middle/Last)BirthdateSchool/GradeSocial Security NumberIf separated, state the current parenting time routine and for how long:

Any other minor children residing with either party: 1

Full Name (First/Middle/Last)BirthdateResidential AddressWhose Child

Health Insurance Information for Children
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Name of ChildrenName of Policy HolderName of Insurance CO/HMOPolicy/Certificate/Contract No

Other Insurance
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Name of ChildrenName of Policy HolderName of Insurance CO/HMOPolicy/Certificate/Contract NoOTHER TYPES OF INSURANCE AN PREMIUMS PAID

Has either party applied for or are receiving public assistance? If yes:
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Who is receiving?Type of Assistance (Bridge card, Medicaid, etc.)Case #

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Important: If you do not wish to have any mail sent to your address, sign here:
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SignaturePrint NameDate

If so, we need an alternate address in the meantime (i.e., family member, friend, or work). Please provide:
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AddressCityStateZip

If your prefer court documents to be sent by email, please provide:
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Custody Intake

How did you hear about us? (Select One)
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Client Information
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Please list any:
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Children

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Health Insurance Information for Children
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Other Insurance
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Has either party applied for or are receiving public assistance? If yes:
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Important: If you do not wish to have any mail sent to your address, sign here:
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If so, we need an alternate address in the meantime (i.e., family member, friend, or work). Please provide:
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If your prefer court documents to be sent by email, please provide:
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8445 South Saginaw Street,
Suite 300
Grand Blanc, MI 48439

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Custody Intake

How did you hear about us? (Select One)‍

Client Information‍

Please list any:‍

Children

‍

Health Insurance Information for Children‍

Other Insurance‍

Has either party applied for or are receiving public assistance? If yes:‍

Important: If you do not wish to have any mail sent to your address, sign here:‍

If so, we need an alternate address in the meantime (i.e., family member, friend, or work). Please provide:‍

If your prefer court documents to be sent by email, please provide:‍

8445 South Saginaw Street,Suite 300Grand Blanc, MI 48439

How did you hear about us? (Select One)
‍

Client Information
‍

Please list any:
‍

Health Insurance Information for Children
‍

Other Insurance
‍

Has either party applied for or are receiving public assistance? If yes:
‍

Important: If you do not wish to have any mail sent to your address, sign here:
‍

If so, we need an alternate address in the meantime (i.e., family member, friend, or work). Please provide:
‍

If your prefer court documents to be sent by email, please provide:
‍

8445 South Saginaw Street,
Suite 300
Grand Blanc, MI 48439