HLG – CONFIDENTIAL QUESTIONNAIRE – NARRATIVE FOR SEPARATION

Today's Date*

How were you referred to our firm?

Client’s Contact Information

Name*

First Middle Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Fax

Is this a confidential fax?

Should we call before faxing?

Email

Alternate Email

Client’s Employment Information

Name of Employer

Employment Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Extension

Fax

Is this a confidential fax?

Should we call before faxing?

What is the best way to contact you?

Are there any special instructions for contacting you? (i.e. certain times of day, days of the week, don’t leave detailed message)

Emergency Contact

Name

First Last

Phone

Spouse's Contact Information

Spouse Name

First Middle Last

Spouse Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Spouse Home Phone

Spouse Cell Phone

Spouse Email

Spouse’s Employment Information

Name of Spouse's Employer

Spouse's Employment Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Spouse Work Phone

Age

Your Date of Birth

Spouse's Date of Birth

Particulars of Your Marriage

Date of Marriage

Date of Cohabitation

City or Place of Marriage

Date of separation:

At the time of the marriage, you were:

At the time of the marriage, your spouse was:

Please provide any surname either you or the other party may have previously used:

Child Details

List all children of this marriage, incl. middle name, birthdate, school attending and grade.

Did you have children from this marriage?

Yes
No

Child 1

Full Name

First Middle Last

Birthday

School

Grade

Resides With

Child 2

Full Name

First Middle Last

Birthday

School

Grade

Resides With

Child 3

Full Name

First Middle Last

Birthday

School

Grade

Resides With

Child 4

Full Name

First Middle Last

Birthday

School

Grade

Resides With

Other Children

Did you have children from another marriage?

Yes
No

Child 1

Full Name

First Middle Last

Birthday

School

Grade

Resides With

Child 2

Full Name

First Middle Last

Birthday

School

Grade

Resides With

Child 3

Full Name

First Middle Last

Birthday

School

Grade

Resides With

Child 4

Full Name

First Middle Last

Birthday

School

Grade

Resides With

Home

Do you and your spouse own a home?

Yes
No

If you own a home in joint tenancy with your spouse, do you wish to sever joint tenancy of your home now?

Do you and your spouse have joint debts (including credit cards, mortgage, personal loans, line of credit, business debts)?

Business Interests

Please provide the name of any business interest in which either you or the other party may have had an interest from inception of the interest to the present.

Will

Do you have a will?

Yes
No

Would you like an appointment to discuss a Will and Power of Attorney?

Yes
No

Date of appointment

Time of appointment

:

Please complete a detailed narrative under each of the following headings:

History of dating:

History of cohabitation, if any:

Circumstances of note surrounding your wedding:

Respective assets and liabilities as of today:

Respective education histories indicating income earned where possible:

Division of labour during marriage:

Any special needs pertaining to any child, either from current relationship or previous relationships:

History of physical and or emotional abuse:

Spouses “admissions” and/or threats:

History of addictions of either party:

Any pertinent medical history of either party and treatment:

Your objectives from a financial and non-financial perspective.

To assist us in representing you, please complete the following information, which will be kept
completely private and confidential.

Halpern Law Group – Confidential Questionnaire – Narrative for Separation

Client’s Contact Information

Client’s Employment Information

Emergency Contact

Spouse's Contact Information

Spouse’s Employment Information

Age

Particulars of Your Marriage

Child Details

Child 1

Child 2

Child 3

Child 4

Other Children

Child 1

Child 2

Child 3

Child 4

Home

Business Interests

Will

Please complete a detailed narrative under each of the following headings:

To assist us in representing you, please complete the following information, which will be kept completely private and confidential.

Halpern Law Group – Confidential Questionnaire – Narrative for Separation

Client’s Contact Information

Client’s Employment Information

Emergency Contact

Spouse's Contact Information

Spouse’s Employment Information

Age

Particulars of Your Marriage

Child Details

Child 1

Child 2

Child 3

Child 4

Other Children

Child 1

Child 2

Child 3

Child 4

Home

Business Interests

Will

Please complete a detailed narrative under each of the following headings:

To assist us in representing you, please complete the following information, which will be kept
completely private and confidential.