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Family Information Statement - Washington

Family Information Statement Form. This is a Washington form and can be used in Family Law Superior Court Clark Local County .
 Fillable pdf Last Modified 9/8/2014
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CLARK COUNTY SUPERIOR COURT FAMILY COURT SERVICES Family Information Statement If there is not enough room to answer any question, attach a separate page. 1. 2. 3. 4. 5. 6. 7. 8. Your name __________________________________________________________ Age Phone (H) Date of birth Place of birth __________________ (W) ________________ Other ________________ Address________________________________City/State/Zip___________________ Occupation __________________________________________________________ Employer's Name and Address ___________________________________________ Name of other party (or parties) in your case_________________________________ Names of all other persons living in your residence, including adults and children Name _________________ _________________ _________________ _________________ _________________ 9. 10. 11. Relationship ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Date of birth _________ _________ _________ _________ _________ Provide the following information about your family of origin: Your Mother's name ____________________________________________________ Residence ___________________ Occupation _____________________________ Your Father's name ____________________________________________________ Residence ____________________ Occupation _____________________________ Your brothers and sisters Name Age Residence ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 12. 13. 14. Has anyone in your family (parents or siblings) abused drugs or alcohol now or in the past? yes mental or emotional difficulties? yes yes Family Information Statement Form No. DR-002 no (circle one) no (circle one) no (circle one) Has anyone in your family (parents or siblings) been hospitalized or received medication for Has anyone in your family (parents or siblings) been arrested or convicted for any crime? Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 15. 16. 17. 18. Has anyone in your family (parents or siblings) been investigated for child abuse? yes Were your parents ever separated or divorced? yes no no (circle one) (circle one) At what age did you move out of your parents' home?_________________________ Provide the following information about your school history: Did you graduate from High School? Did you attend college? Were you in special education classes? yes yes yes no no no (circle one) (circle one) (circle one) Provide the following information about your work history: 19. For all your jobs prior to and including your current employment (beginning with your current position and including the past five years), provide: Employer _____________ _____________ _____________ _____________ 20. 21. 22. 23. 24. 25. 26. Location _____________ _____________ _____________ _____________ Salary _____________ _____________ _____________ _____________ Work Hours _____________ _____________ _____________ _____________ Dates _____________ _____________ _____________ _____________ Have you ever been fired or laid off from any job? yes no (circle one) Provide the following information about your relationship and marital history: When did you meet the other parent? __________________________ If you lived together, give dates: ______________________________ Date engaged (if applicable) _________________________________ Date married (if applicable) __________________________________ Date of most recent separation (if applicable) ____________________ List your residences during past five years and dates you lived at each. Dates ______________ ______________ ______________ ______________ ______________ Address including City and State __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ 27. Name ______________________________ ______________________________ ______________________________ ______________________________ Family Information Statement Form No. DR-002 List names and ages of all of your children, including of other relationships: Age ______________ ______________ ______________ ______________ Page 2 American LegalNet, Inc. www.FormsWorkFlow.com 28. Have you ever been in psychotherapy or counseling? Dates ________________________ ________________________ yes no (circle one) Address ________________________ ________________________ If yes, give dates, names and complete addresses of therapists. Name of Therapist ________________________ ________________________ 29. Have you ever been hospitalized for mental or emotional difficulties? yes no (circle one) If yes, give dates, name of hospital, and location Dates ________________________ ________________________ Location ________________________ ________________________ Name of Hospital ________________________ ________________________ 30. Has any physician ever prescribed medication for any mental or emotional difficulties? yes no (circle one) If yes, give dates, medication, name of physician, and address. Dates __________ __________ __________ Medication ______________ ______________ ______________ Currently Taking? _______________ _______________ _______________ Address Name of Physician __________________ _____________ __________________ _____________ __________________ _____________ 31. Have you ever been arrested and/or convicted of any crime, including felonies and misdemeanors, and including juvenile and adult offenses? yes no (circle one) Disposition __________________ __________________ __________________ __________________ If yes, provide dates, place, and circumstances of each arrest/conviction: Place (City/State) ________________ ________________ ________________ ________________ 32. 33. 34. Date _______ _______ _______ _______ Circumstances _____________________________ _____________________________ _____________________________ _____________________________ Have you ever been under supervision by probation, parole or community service? yes no (circle one) Do you c
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