Client Intake Form

Thank you so much for contacting our law office! Please read the privacy policy below, and then fill out this form with as much information as you have. The more information you provide, the better we may serve you.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security numbers are most often used to positively identify parties. Most courts require Social Security numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

CLIENT INFORMATION

Contact information: Client

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

EMERGENCY CONTACT

Contact information: Emergency Contact

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

EDUCATION

EMPLOYMENT AND MILITARY HISTORY

MEDICAL HISTORY/MENTAL HEALTH HISTORY

INFORMATION ABOUT ARREST

COURT INFORMATION

Regarding Your Arraignment

OTHER ARREST INFORMATION

WITNESSES

BOND INFORMATION

PRIOR CRIMINAL RECORD

(INCLUDING JUVENILE RECORD)

PROBATION OR PAROLE

COMMENTS MAY BE OF VALUE

THANK YOU

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.

Today’s Date:

CLIENT INFORMATION

Contact information: Client

Social Security #:

Are you known by any other names?

Marital Status:

Do you have any children?

EMERGENCY CONTACT

Contact information: Emergency Contact

Emergency Contact Relationship:

EDUCATION

Highest Education:

EMPLOYMENT AND MILITARY HISTORY

Are you currently employed?

Did you serve in the armed forces?

MEDICAL HISTORY/MENTAL HEALTH HISTORY

What medications do you take?

Have you ever received mental health or substance abuse counseling?

Have you had any chronic health problems?

INFORMATION ABOUT ARREST

County of Arrest:

Case # or Summons #:

Date of Arrest:

Date of Alleged Crime:

Location:

Charges:

COURT INFORMATION

Court County:

Upcoming Court Date:

OTHER ARREST INFORMATION

Was anyone else arrested?

Have you discussed the alleged crime with anyone else?

Describe The Events Leading Up to the Arrest In Order:

WITNESSES

List Any Witnesses to The Alleged Crime:

List Any Alibi Witnesses:

BOND INFORMATION

Custody status:

Name of jail that client is detained in:

What are the financial conditions of bail/bond?

List Any Special Bond Conditions:

PRIOR CRIMINAL RECORD

Prior Arrest Charge #1:

Prior Arrest Charge #2:

Prior Arrest Charge #3:

PROBATION OR PAROLE

Are you currently on probation or parole?

COMMENTS MAY BE OF VALUE

Any other information that may be of value to your case?

How did you learn about our office?

THANK YOU