FACLC Intake Form

We cannot guarantee to represent you.

Please note that your review of this Web site and/or completion of our intake process does not guarantee that we will be able to represent you, and does not establish an attorney-client relationship with our office, or any of its attorneys.

About You

First Name
Middle Name
Last Name
Maiden Name
Previous Names
Date of Birth
Marital Status

Contact Information

Street
City
State
Home Phone
Okay to call home?
Work Phone
Okay to call work?
Alternative Phone
Okay to call?

Income and Assets

Are you currently employed?

If yes, where do you work?

What is your gross monthly salary (before taxes)? $

Are you currently receiving any of the following types of government assistance?

General Assistance (GA) AFDC/CALWORKS/TANF
SSI Food Stamps

How many adults live in your home?

Do these adults contribute financially to your support?

If yes, how much? $

How many minor children (under age 18) live with you more than 50% of the time?

Do you receive child support for any of these children?

If yes, how much? $

Do you receive any income from other sources?

If yes, how much? $

Do you own a home?

If yes, what is the equity in that home? $

Do you have any savings, securities, property or investments valued higher than $25,000?

If yes, what is the value? $

Case Status

Do you have a family law case in Marin County?

If yes, do you have a court date?

If yes, when?

Do you have a family law case outside of Marin County?

Do you have an attorney?

If yes, who?

Opposing Party Information

First Name
Middle Name
Last Name
Maiden Name
Previous Names
Date of Birth
Street
City
State
Home Phone
Work Phone

Is the opposing party a Marin County resident?

If no, what county?

Is the opposing party represented by an attorney?

If yes, who?

What is your relationship with this person?

If you lived together, date separated?

If you were married, date of marriage?

Do you have any children with the opposing party?

Name of child

Date of Birth

Child currently lives with

Name of child

Date of Birth

Child currently lives with

Name of child

Date of Birth

Child currently lives with

Name of child

Date of Birth

Child currently lives with

Are there any current custody orders regarding these children?

If yes, in what county were those orders made?

Statistical Information

Race

If other, what race?

How did you hear about the Family & Children's Law Center?