Client Questionnaire - Richardson Bloom & Lines

	Client:	Opposing Party:
Name:

Information on Current Marriage:
Date of Marriage:
City/State of Marriage:
Date of Separation: (i.e. last time you had marital relations)
Wife's Maiden Name:
Maiden Name to be Restored:	Yes No
How long did/have you lived at the marital home?
How long have you lived in that county?
How long have you lived in Georgia?
Are you interested in reconciliation?	Yes No
Is your spouse interested in reconciliation?	Yes No
Have you tried marriage counseling?	Yes No
If yes, when and with whom?

Health Information:
Are you, your spouse, or any of your children currently receiving any medical or psychological treament?	Yes No
If yes, please specify who is receiving treatment, who provides the service and what medication or treatments received:
Who provides health insurance for the family?	Husband Wife

Other:
Has your spouse consulted an attorney regarding this matter as far as you know?	Yes No
If yes, please indicate the attorney's name:
Do you have a will?	Yes No
Is your will in need of revision?	Yes No
Who are the benficiaries of your will?
Name of your accountant:
Are there bank accounts, lines of credit, stock and investment accounts or other accounts to which your spouse has access?	Yes No
If yes, please specify:
Does your spouse have in his or her possession credit cards for which you are responsible?	Yes No
Have you signed anything which may affect the case, including prenuptial or postnuptial agreements, or other documents presented by your spouse?	Yes No
If yes, please specify:
Have you or your spouse sold any real estate property in the last five years?	Yes No
If yes, please specify:

Has your spouse consulted an attorney regarding this matter as far as you know?

Yes No

If yes, please indicate the attorney's name:

Do you have a will?

Yes No

Is your will in need of revision?

Yes No

Who are the benficiaries of your will?

Name of your accountant:

Are there bank accounts, lines of credit, stock and investment accounts or other accounts to which your spouse has access?

Yes No

If yes, please specify:

Does your spouse have in his or her possession credit cards for which you are responsible?

Yes No

Have you signed anything which may affect the case, including prenuptial or postnuptial agreements, or other documents presented by your spouse?

Yes No

If yes, please specify:

Have you or your spouse sold any real estate property in the last five years?

Yes No

If yes, please specify:

Mailing Address (if different):
Street:
City:
State:
Zip:
County:

Contact Information (check preferred method):
Home Phone
Work Phone
Mobile Phone
Fax Number
Email Addresss

Children of Current Marriage:
Name:	Date of Birth:	Resides With:

Are any other children expected?	Yes No
Do any of the children have special needs?	Yes No
Please specify any special needs of the children:

Where do the children attend school?
Child's Name:	Attends:	Monthly Tuition:	District:

Background Information:
	Client:	Opposing Party:
Date of Birth:
Place of Birth:
Employer:
Position/Title:
Annual Salary:
Annual Bonus:
Employed Since:
Highest Level of Education Earned:
Religious Affiliation (if any):
Vehicle(s) Make/Model/Year/Color:
Vehicle Registration Name:

Information on prior divorce if applicable:
Number of prior marriages:
Name(s) of prior spouse(s):
Date(s) of prior divorce(s):
County and State of prior divorce(s):
Names/ages of child(ren) from prior marriage(s):
Child support order for those child(ren):
How much received/paid in child support:

Name of Insurance Companies:	Health:	Vision:	Dental:
Name of Insurance Companies: