Custody Intake Form

Custody Intake Form

This Custody Intake Form is completed by Client Name: and Intake Representative: on Date: .

RECITALS

WHEREAS, Client Name is the parent or legal guardian seeking legal assistance regarding the custody, parenting time, and related decision-making authority for one or more minor children; and

WHEREAS, the Intake Representative is an authorized representative of the law firm or agency that will evaluate the facts, collect documents, and, if retained, represent Client Name in custody-related proceedings; and

WHEREAS, Client Name requests that the Intake Representative collect pertinent information and evidence to assess jurisdictional issues, immediate safety concerns, and the appropriate legal relief to pursue on behalf of the minor child(ren).

NOW, THEREFORE, the parties provide the following information and certifications to facilitate initial case assessment and potential legal action.

1. IDENTIFICATION OF PARTIES

2. CHILD(REN) INFORMATION

Provide full legal name and birthdate for each minor child. Add additional sheets if necessary.

Date of Birth:

Date of Birth:

3. EXISTING ORDERS AND JURISDICTION

Does a court already have jurisdiction or existing custody/parenting-time orders for any child listed?

4. NATURE OF REQUESTED RELIEF

Indicate the type of proceedings sought. Select all that apply and provide a brief factual explanation.

5. SAFETY, ALLEGATIONS, AND PROTECTIVE ISSUES

Report any allegations or safety concerns that could affect custody or parenting time decisions. Provide dates, locations, and supporting evidence where possible.

6. EDUCATION, MEDICAL, AND SPECIAL NEEDS

7. FINANCIAL AND EMPLOYMENT INFORMATION

8. DOCUMENTS AND EVIDENCE PROVIDED

Check all documents provided or to be obtained by the Intake Representative.

9. CERTIFICATIONS, AUTHORIZATIONS, AND ACKNOWLEDGMENTS

By signing this form, Client Name certifies that the information provided in this intake is true and correct to the best of Client Name's knowledge. Client Name authorizes the Intake Representative to obtain records, including but not limited to medical, educational, and law enforcement records, necessary for case evaluation and representation. Client Name understands that submission of this form does not by itself create an attorney-client relationship; such relationship arises only upon the execution of a separate engagement agreement where required.

Client Name acknowledges that all known legal conflicts, prior related proceedings, and material facts have been disclosed above or on attached pages. Client Name further understands that withholding material facts may result in termination of representation.

10. NOTICES, AMENDMENTS, AND MISCELLANEOUS

Notices given under this form shall be effective when sent to the contact information provided in this form. Any amendment to the information supplied must be provided promptly in writing. The Intake Representative may rely on the addresses and contacts provided herein for service and communication.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This form and the parties' rights and obligations arising directly from this intake shall be governed by the laws of the state where the Intake Representative's office conducts case intake, except where controlling jurisdictional law requires otherwise. This intake constitutes the entire written statement of facts and authorizations provided for initial assessment and supersedes any prior written intake submitted in relation to this matter. If any provision of this form is held invalid, the remaining provisions shall remain in full force and effect.

12. COUNTERPARTS AND SIGNATURE

This Custody Intake Form may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

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