Intake Form II

Name

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Street Address

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City

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State

Please choose your state of residence.

Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming ZIP Code

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Email Address

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Home Phone Number

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Business Phone Number

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Mobile Phone Number

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Fax Number

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If you are or have been known by other names, list them here.

Please list other names you are or have been known by.

What is your marital status?

Please indicate your marital status.

Select statusSingleMarriedDivorcedSeparatedWidowed

If this matter involves a business you own or run, list the business name, address and contact number.

Please list the business name, address and contact number.

If a business is involved, how is the business organized?

Please indicate how the business is organized.

Select organizationSole ProprietorshipPartnershipLimited Liability CompanyLimited PartnershipProfessional CorporationS CorporationC CorporationOther

If you are employed, list the business name, address, and contact number of your employer.

Please list the business name, address and contact number of your employer.

Please indicate the area of law your situation involves.

Please indicate the area of law your situation involves.

Area of lawAdministrative LawAdmiralty / Maritime LawAdoptionAgriculture LawAlternative Dispute ResolutionAnimal BitesAntitrust & Trade RegulationAviationAviation & Mass Transit Accid.Banking / Finance LawBankruptcy LawBusiness & Commercial LawBusiness OrganizationsChild SupportCivil RightsConstruction LawConsumer ProtectionContractsCriminal LawCriminal Law / FederalCustody / VisitationDiscriminationDivorceDUI / DWIEducation LawElder LawEmployment Law / EmployeeEmployment Law / EmployerEnergy LawEnvironmental LawEstate PlanningEthics/Professional Resp.GeneralFranchisingGovernment Agencies/ProgramsGovt. ContractsHealth & Health Care LawImmigration / NaturalizationInsurance LawIntellectual Property LawInternational LawInternet / CyberspaceLabor LawLandlord / TenantLegal MalpracticeLitigation / AppealsMedical Malpractice LawMilitary LawMotor Vehicle AccidentsNursing HomePatentPersonal InjuryPersonal Injury / DefensePremises LiabilityProbate Estate AdministrationProducts Liability LawProfessional Malpractice LawReal Estate LawScience / Technology LawSecurities LawSexual HarassmentSocial Security / DisabilityState / Local / Municipal LawTaxation LawToxic SubstancesTrademarksTraffic ViolationsTransportation LawTrustsWillsWorkers’ Compensation LawWrongful Death Describe your situation, including any relevant dates.

Please describe your situation, including any relevant dates.

How would you rate the urgency of your legal need?

Please rate the urgency of your legal need.

Select urgencyExtremely UrgentUrgentStandardInformational Only

If this matter involves others, list their names, addresses and relationship to you, if any.

Please list the names, addresses and relationship to you of the others involved in this situation.

If you have related documents, list their names and dates.

Please list the names and dates of your related documents.

If there are other helpful documents that you don’t have access to, list their names and dates.

Please list the names and dates of the other helpful documents you don’t have access to.

Describe how this situation has impacted you.

Please describe how this situation has impacted you.

Describe what you would like to happen to resolve this issue.

Please describe what you would like to happen to resolve this issue. What is the outcome you desire?

If other attorneys have worked on this matter, list their names, addresses and a description of their involvement.

Please list the names, addresses and a description of the other attorneys’ involvement in this matter.

Describe any special concerns.

Please describe any special concerns.

How did you hear about this Web site?

How did you hear about this Web site? Please choose one.

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The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.