Intake Form

First Name:
Last Name:
Phone:
Email:
Address:
How Did You Hear About Our Office?
What Topics Would You Like To Discuss With The Attorney For Your Consultation? Divorce Post Divorce Child Support Restraining Order/Domestic Violence Parenting Time/Visitation Spousal Support/Alimony Child Custody Other

Please fill out the following questions to the best of your ability. When the attorney has all the available information, you can make the most of your consultation time to discuss the issues and questions you may have. If you do not complete the form fully, your consultation time will be taken up completing these necessary questions to provide a personalized consultation.

For ALL MATTERS, please fill out the following information.

Your Occupation:
Your Gross/Total Income (Including Any Current Alimony, Child Support OR Other Source Of Income).
Your Spouse And/Or Other Parent Occupation:
The Spouse And/Or Other Parent Gross/Total Income (Including Any Current Alimony, Child Support OR Other Source Of Income).
Is There A Pending Hearing Or Application In The Court?
Is There Any Type Of Prior Order On Your Family Matter?
For Consultations regarding DIVORCE please fill out the following questions. Date Of Marriage:
Location Of Marriage:
Are You Separated From Your Spouse?
Does Your Spouse Live In A Different Residence?
Do You Have Children Together?
Do You Have Property/Real Estate?
Do You Have Stocks, Bonds, Pension?
For Consultations regarding DIVORCE INCLUDING CHILDREN, CHILD SUPPORT, CHILD CUSTODY AND VISITIATION please fill out the following questions: Number Of Children In This Relationship:
Number Of Total Children (Including Other Relationships):
Age Of Child/Children:
How Many Child/Children Are In College:
I Am The Child's / Children's:
The Child/Children Are Currently:
The Current Visitation Is:
Current $ Amount Paid Per Month In Child Support:
For Consultations regarding TEMPORARY RESTRAINING ORDER MATTERS please fill out the following questions: What Court Is Your Hearing?
When Is Your Hearing?
Please Provide A Brief Description Of Your Matter:

CONTACT THE LAW OFFICES OF JEFFREY M. BLOOM

Intake Form

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Serving Bergen County, Hudson County, North Jersey