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Home
About
Services
Attorney
Contact
Initial Intake Form
Name
*
First Name
Last Name
Pronouns
*
Date of Birth
*
MM
DD
YYYY
State/Country of birth
*
Email
*
Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Total household income (before taxes)
*
Are you employed?
*
Yes
No
Pay
*
e.g. $20/hour or $50,000/year
Do you receive public benefits? If so, please provide amount and type.
*
e.g. TANF, medical assistance, childcare assistance, food stamps
Please list other sources of income.
*
Please list any other adults in your household.
*
Please include adult children unless they are in school, disabled, or otherwise dependent.
Opposing party's name
*
First Name
Last Name
Opposing party's date of birth
*
MM
DD
YYYY
Opposing party's contact information
*
Email, phone, home address, employer, employer's address/phone, etc.
Are you currently living together?
*
Yes
No
Do they have an attorney? If so, please provide their name.
*
What legal issues would you like to discuss in your consultation?
*
Please list any hearing dates or deadlines coming up within one month.
If your case has been filed, please provide the cause number.
The cause number is located in the top right section of the header on the first page of a court document.
Are you a victim of domestic violence?
*
Domestic violence is a pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner. Domestic violence can be physical, sexual, emotional, economic, psychological, or technological actions or threats of actions or other patterns of coercive behavior that influence another person within an intimate partner relationship. This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone.
Yes
No
Unsure
Have you been accused of domestic violence? Please select all that apply.
*
Yes, by the opposing party
Yes, by someone else
No
Thank you!
