GAL INTAKE QUESTIONNAIRE

Answer all questions completely.

CONFIDENTIALITY: The information you enter in this questionnaire is confidential and protected by Attorney-Client Privilege. The information will not be disclosed to anyone outside of this office, except in the course of rendering legal services on your behalf or as otherwise provided by law.

First name

Last name

Social Security Number

Best phone number to reach you

Primary Phone Number

Alternate Phone Number

Date of Birth

Driver's License Number

Address

Do you own or rent your property?

Own

Rent

Name on lease or deed

How many bedrooms and baths are in the residence?

Date of residency at your current address:

List any previous residences in the past five (5) years and dates resided in each:

Emergency Contact Name

Emergency Contact Address

Emergency Contact Phone Number