Client Intake Information

Please fill out this form so we can learn about you and your unique legal needs.

25%

How did you hear about us?
Name*
FirstLast
Social Security No.*
Driver's License No.*
Date of Birth*
Current Address*
Street AddressAddress Line 2City

StateZIP Code
Permanent Address*
Street AddressAddress Line 2City

StateZIP Code
Home Phone*
Cell Phone*
Work Phone
Email
Marital Status*
Spouse's Name
FirstLast
Spouse's Phone
Spouse's Address
Street AddressAddress Line 2City

StateZIP Code
Children (Names, Ages, Addresses)
We will not discuss your case with anyone without your consent. If you want our office to communicate with a friend or family member, please state their name

Please tell us in your own words what happened. Please be as detailed as possible.*
What is your expectation about what should happen to you?*
What result are you looking for?*
Are you presently on Parole/ Probation?*
Probation Officer
Probation Location
Prior Criminal Record (Please list all misdemeanor and felony convictions, as well as drunk driving offense) (If none, please write N/A)*

Are you currently enrolled in school?*
If so, where?
Are you currently employed?
Employment (Employer name, your position, length of employment and supervisor)*

Please include your Present Employment as well as Recent Past
Father's Name
FirstLast
Phone
Address
Street AddressAddress Line 2City

StateZIP Code
Mother's Name
FirstLast
Phone
Address
Street AddressAddress Line 2City

StateZIP Code
Signature*
- I agree
By clicking “I Agree” you agree that the information you provided is completely accurate, and that this acts as an Electronic Signature.