Date of Intake
Intake Completed By
Full Legal Name (required)
Other Names Used (Maiden / Alias)
Date of Birth
Last 4 Digits of SSN
Driver's License Number
State Issued
Home Address
Mailing Address (if different)
Primary Phone (required)
Secondary Phone
Email Address (required)
Preferred Method of Contact PhoneEmailText
Best Time to Contact
Employer Name
Occupation
Employer Address
Work Phone
Length of Employment
Monthly Income (optional)
Name of Opposing Party / Defendant
Address
Phone
Attorney for Opposing Party (if known)
Select all that apply Property DamageWrongful ForeclosureReal Estate DisputeContract DisputeDebt Collection DefenseFraud / MisrepresentationLandlord / TenantProbate DisputeConstruction DisputeBusiness DisputeBankruptcy Related Matter
Other (please specify)
Date of Incident or Dispute
Location of Incident
Description of the Matter (required)
Damages Suffered (select all that apply) Property DamagePersonal InjuryEmotional DistressFinancial LossLoss of PropertyLoss of Income
Estimated Amount of Damages
Has a lawsuit already been filed? YesNo
Court Name (if applicable)
Case Number (if applicable)
Case Status (if applicable) PendingJudgment EnteredAppeal PendingCase Closed
Have you received any of the following? Court SummonsComplaintNotice of HearingForeclosure NoticeWrit of PossessionNotice of SaleCollection Letter
Deadline to Respond
Select all documents you have available ContractsCourt FilingsLetters / EmailsPhotographsPolice ReportsMedical RecordsFinancial StatementsLoan DocumentsMortgage DocumentsBankruptcy Filings
Other Documents
Name
Relationship
Have you consulted another attorney regarding this matter? YesNo
Attorney Name (if applicable)
Law Firm (if applicable)
Reason for Change
Insurance Company
Policy Number
Claim Number
Adjuster Name
Adjuster Phone
Select one ReferralInternet SearchSocial MediaAdvertisementFormer ClientOther
If referral, who referred you?
Additional Notes or Comments
