Intake Form

1. Client Information

Salutation

First Name

Middle Name

Last Name

Email

Phone Number (Required for Text Contact)

1A. Preferred Contact Method(s)

Please check all preferred methods for us to contact you:

Text Mail Email

1B. Authorized Contact (Optional)

List one person (e.g., spouse, family member) we may speak with regarding your case:

Authorized Contact Name

Authorized Contact Phone

2. Address

Street Address

City

State

Zip Code

3. Driver's License and Date of Birth (Optional)

Date of Birth

Driver's License #

License State

4. Case Details

Court Date (if known)

County Where Charged

Court Room (if known)

File Number (if known)

5. Charges

Charge 1

Charge 2

Charge 3

828-333-4867

828-333-4867

Client