Prepared by Norman Pickell, a family law lawyer based in Goderich, Ontario.
Print off this page and then complete it as much as possible
by printing the answers
before taking it to your lawyer.
Information About You:
Full Name: _______________________________
Date:
_________________
Full Mailing Address (incl. Postal Code):
____________________________________________________
_____________________________________________________
Town, City or Township ______________________
County _____________
Phone #: Home ______________________
Phone #: Work _____________________
Birth Date ____________________
Birthplace ________________________
How long have you resided in the above municipality ? ___________
Have you resided in Ontario continuously for the past 12 months ?
Yes _____
No _____
If No, where have you resided during that period of time ?
________________________________
Your occupation ______________________________
Information About Your Spouse:
Full Name: ________________________________
Date: ________________
Full Mailing Address (incl. Postal Code):
___________________________________________________
___________________________________________________
Town, City or Township _____________________
County _______________
Birth Date ____________________ Birthplace _________________
How long has your spouse resided in the above municipality ?
__________________________________
Has your spouse resided in Ontario continuously for the past 12 months ?
Yes
_____ No _____
If No, where has your spouse resided during that period of time ?
____________________________
Your spouse's occupation ______________________________
Separation:
Date of separation _____________________
Do you and your spouse have a signed Separation Agreement ?
No ________ Yes
________
(If Yes, please bring a copy of it with you to your appointment with your
lawyer.)
Are all the terms of the Separation Agreement being followed ?
Yes _______ No
_______
If No, details ______________________________________________________
______________________________________________________
______________________________________________________
Reconciliation:
Is there a possibility of reconciliation ?
No __________ Yes __________
If Yes, details ___________________________________________
_______________________________________________________
_______________________________________________________
Have there been attempts made to reconcile ?
No _________ Yes __________
If Yes, details ____________________________________________
________________________________________________________
________________________________________________________
Information About Your Marriage:
Date _______________________ Place ______________________________
Wife's surname immediately before marriage___________________
Wife's surname at birth _____________________________
Husband's surname immediately before marriage _______________
Husband's surname at birth _____________________________
Marital status of husband at time of marriage _________________
Marital status of wife at time of marriage _____________________
Do you have your marriage certificate ?
Yes ____________ No ____________
(If Yes, please bring it with you to your appointment with your lawyer.)
Children:
Do you have any children under 18, (or over 18 who are still under the care -
in some way - of you or your spouse) ?
No ________ Yes ________ If Yes:
Child # 1: Full name of child ________________________________
Address of child __________________________________________
Date of birth _____________________________
Name of school attending __________________________________
Grade or year ____________________________________
Person with whom child is living ______________________________
Length of time with that person ________________
Child # 2: Full name of child ________________________________
Address of child __________________________________________
Date of birth _____________________________
Name of school attending __________________________________
Grade or year ____________________________________
Person with whom child is living ____________________________
Length of time with that person ________________
Child # 3: Full name of child _____________________________
Address of child _______________________________________
Date of birth ____________________________
Name of school attending ________________________________
Grade or year ____________________________________
Person with whom child is living ___________________________
Length of time with that person ________________
Child # 4: Full name of child _______________________________
Address of child _________________________________________
Date of birth ____________________________
Name of school attending __________________________________
Grade or year ____________________________________
Person with whom child is living ______________________________
Length of time with that person ________________
Custody and Access (Visiting) Arrangements:
If you have a Separation Agreement, are you satisfied with what is said in
the agreement about custody and access ?
Yes _______ No _________
If No, please explain ________________________________________________________
________________________________________________________
________________________________________________________
If there is already a Court Order, are you satisfied with what is said in
that Order about custody and access ?
Yes _________ No _________
If No, please explain _______________________________________________________
_______________________________________________________
_______________________________________________________
If there is neither a Separation Agreement nor a Court Order, what do you
suggest for custody and access ?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Does your spouse agree with what you suggest?
Yes ________ No ________
If No, please explain ______________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Please tell us what the present visiting arrangements are for the parent who
does not have the children living with him or her ?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Do you expect that there will be any material changes in either your
circumstances or the circumstances of your spouse which will affect the children
in the future ?
No ________ Yes _________
If Yes, please explain
_________________________________________________________
_________________________________________________________
_________________________________________________________
Child Support:
What is your annual income ? ________________________
What is the annual income of your spouse ? ____________________
Please tell us what the present arrangements are between you and your spouse
for the support of your children (including whether there are any arrears of
child support) ?
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Educational Needs of Children:
Are the educational needs of the children being met?
Yes ______ No ______
If No, please give details _____________________________________
__________________________________________________________
__________________________________________________________
Other Court Proceedings:
Please tell us about ALL other Court proceedings with reference to
your marriage or any child of your marriage (including the name of the Court and
the kind of Order that was made):
(If there are such Court Orders, please bring copies of each Order to your
appointment with your lawyer.)
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Matters Other Than Divorce, Custody, Access and Child Support:
Have you and your spouse divided your assets to your satisfaction ?
Yes
________ No _______
If No, details ______________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Are you expecting to receive spousal support from your spouse ?
No ______ Yes
_______
If Yes, details ______________________________________________
__________________________________________________________
__________________________________________________________
Are either you or your spouse wanting anything more than a divorce ?
No
______ Yes _______
If Yes, details __________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
When you have completed this Form as much as you can, please bring this Form
to your lawyer at the time of your FIRST interview.
_____________________________________
Signature of person completing this form
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