Your Full Name Phone City and State of Residence Your Email Best method of contact PhoneEmail Language Preference? EnglishArabicBanglaUrduother Place of Birth Age Was Civil Marriage done? If yes, when? Where did the marriage take place? Is this your first marriage? Is this your husband's first marriage? Where is your family originally from? What is your highest level of education? Are you currently employed? If yes, full-time or part-time? Spouse Full Nam Spouse Phone Spouse City, State and Country of Residence Spouse Email Best method of contact? PhoneEmail Spouse Language Preference? EnglishArabicBanglaUrduother Spouse’s Place of Birth Spouse’s Age Where is the spouse’s family originally from? What is the spouse’s highest level of education? Is the spouse currently employed? If yes, full-time or part-time? How long have you been married to this spouse? Do you have children together? If yes, how many? Are you a practicing Muslim? Please explain: Five-time daily salah? Fasting? Is your spouse a practicing Muslim? Please explain: Five-time daily salah? Fasting? Hijab? In brief, what is the problem in your marriage? (250 character limit) Did your husband ever give you talaq, verbally or in writing? if yes, how many? Is your husband up to date with providing nafaqah (providing housing, clothing, food? Are you living separately? If yes, since when? Was there any attempt of mediation or reconciliation from family or community members? If yes, who? Please provide details, names, contacts and relationships. Are there any cases pending before the courts related to this marriage? Is there any order of protection for either party? If yes, please provide details. Do your walis (responsible relatives) support your decision to seek a khula from your husband? If so, who? Please provide names, contacts and relationships. Have you filed a khula application or similar application with any other organization? If so, please provide details. How did you find out about our services? Δ
