Counseling | The Hemmat Law Group

This intake form helps our counseling team get a sense of your history and objectives.
While these professionals work alongside our legal team, they are responsible for your emotional, rather than legal wellbeing.

Your counselor is protected under the umbrella of confidentiality. You can speak with them freely.

If you understand this and are happy to proceed, please click next.

Your Name

Name(Required)

How do you prefer to be contacted?

Please let us know the best way to contact you to schedule your evaluation(Required)

Email

Phone Call

Text Message

What number should we text you on?

PhoneText(Required)

What number should we call you on?

PhoneCall(Required)

What email address should we contact you at ?

EmailChoice(Required)

Current relationship status

Current relationship Status(Required)

Partnership/Marriage

Separated

Never Married

Other

If separated, how long?

Number of months/years(Required)

Please provide any additional information about your relationship status.

Are there children involved?

Are there children involved?(Required)

Yes

No

If so, please list names and ages.

Is there a Separation Agreement/Co-parenting arrangement/Custody Order?

Is there a Separation Agreement/Co-parenting arrangement/Custody Order?(Required)

Yes

No

What are the general terms of
the order/ or arrangement?

Please share details of the Opposing Party’s attorney (if applicable)

Are there any extenuating circumstances in
your relationship that we should be aware of – e.g. alcohol/substance abuse, communication issues,
extreme anger, domestic abuse, or violence, including emotional and financial abuse), etc.

Are there any extenuating circumstances in your story that we should be aware of – e.g. alcohol/substance abuse, communication issues, anger, domestic violence etc.(Required)

Yes

No

If yes, please elaborate on the circumstances.

Are any mental health issues
that we should be aware of?

Are any mental health issues that we should be aware of?(Required)

Yes

No

If yes, please share diagnosis and current treatment plan (if applicable)

Please share any additional detail about contributing factors driving conflict or concern in your case:

What would be most helpful to you through this coaching experience; and what does an ideal outcome look like to you? What are you hoping to gain through this emotional coaching experience; and what is your ideal outcome?

What are the biggest challenges in the relationship or dynamic between you and the other party?

What would best serve you throughout your coaching experience?