Civil Intake Form printable pdf download

DATE: ___________

BAILEY & GALYEN

ATTORNEYS AT LAW

Name _______________________________________________________________________________ DOB: _____________Sex: M ____F____

Last Name

First

Middle

Maiden

Place of birth___________________________________________________________________________________________________________

City

County

State

Country

Social Security Number: _____________________________ Drivers License Number: _______________________________ State_________

Address: __________________________________________________________________________________Apt. #______________________

City: __________________________________________ County: _______________________ State: __________ Zip: ____________________

Home Phone: (________) ____________________________________ Work Phone: (_______) _______________________________________

E-Mail Address: _____________________________________________________Cell Phone: (______) _________________________________

 I authorize emails concerning my case.

 I authorize emails of general interest from Bailey & Galyen.

□ I

(______)_______________________

authorize a follow up call regarding my consultation. If yes, please list a contact number.

Place of Employment: __________________________________________________Job Title: ________________________________________

Address of Employment: _______________________________City_____________ St______Zip_________ Annual Salary________________

Spouse’s Name: ________________________________(Maiden name)_________________________ DOB: ____________________________

Address(if different from yours): _________________________________________City: _____________________State: ______ZIP: ________

Employer: __________________________________________________ Work Phone: _______________________________________________

PERSON FINANCIALLY RESPONSIBLE:

_____________________________________________________ DOB: _____________________

Name

Address:____________________________________City:__________________State:______Zip:________Phone: _______________________

Social Security Number: _____________________________________ Drivers License Number: ________________________State_________

EMERGENCY CONTACT INFORMATION:

_____________________________________________________________________________

Name

Address: ________________________________________________City: _________________________State: _____________Zip: __________

Home Phone: (_______) ___________________________________ Work Phone: (________) ________________________________________

What legal action(s) were you involved in previously, if any? __________________________________________________________________

Have you or family member been involved in any type of accident in the last two years?

Yes_______

No_______

Have you or a family member ever suffered any serious injuries after taking a prescription or non-prescription drug? Yes_____ No _____

Do you currently have a will? Yes ________ No ________

Have you been denied Social Security benefits? Yes __________ No _________

Have you been denied Veterans benefits? Yes ________ No _________

Do you have need of legal assistance for any immigration matter? Yes_________ No _________

Purpose of visit today: __________________________________________________________________________________________________

HOW WERE YOU REFERRED TO US? (Circle one)

Office Sign

I’m a Previous Client

Bar Association

B&G Letter

TV Ad

Radio

Billboard

Website

WebChat

Phonebook: name of book _________________________________________

Friend: Name of Friend________________________________ Other: ___________________________________________________________________

Bailey & Galyen Employee: Name _________________________________ An Attorney: Name of attorney ______________________________________

FOR OFFICE USE ONLY:

INTERVIEWING ATTY __________________

CONFLICT CHECK PNC _________________________ INI____________

CONFLICT CHECK OP ___________________________ INI____________

FEE QUOTED__________________ COST QUOTED _________________

PNC CONTACT ENTERED IN ATO__________________ INI____________

OP CONTACT ENTERED IN ATO___________________ INI____________

DOWN PAYMENT QUOTED___________________

REVISED 6-19-14

Civil Intake Form

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