Client Intake Form

Name

First Name

Last Name

Phone

(###)

###

####

Where did you hear about us?

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current Marital Status

Length of Marriage/Relationship

Date of Separation

Any safety concerns or domestic abuse? If so please share.

Have you had an Order of Protection?

AKA Restraining/Protective Order

Yes

Emergency Contact

Name, Age, Gender of Child (if applicable)

Add anything you'd like to share about your child

Name, Age, Gender of Child (if applicable)

Add anything you'd like to share about your child

Name, Age, Gender of Child (if applicable)

Add anything you'd like to share about your child

Name, Age, Gender of Child (if applicable)

Add anything you'd like to share about your child

Please tell me about your current custody arrangement.

Time division, legal, physical custody specifics if applicable

Provide a summary of your divorce or custody battle.

Describe your goals for our coaching- what do you hope to accomplish?

Are you working with an attorney? If so does your attorney understand high conflict divorce?

Please share the name of your attorney.

What topics are you most interested in exploring? List your top 3:

Examples include:setting boundaries, communication, emotional support, documentation, prep for evaluations, etc.

Are you working with any custody evaluators, minor's counsel (GAL), child welfare services, or other legal professionals?

Please provide an overview.

Are you (or your children) in therapy?

Please provide an overview.

Has there been DCFS/CPS involvement?

Do you have an upcoming court date?

Who is your judge?

What state/county is your court case filed in?

Please share the name of your ex's attorney.

Any additional notes?

eSignature

I acknowledge this serves as my binding signature.

Empowered Outcomes Consulting, LLC

kristina@empoweredoutcomesconsulting.com