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Client Intake Form

Client Intake Form

Please fill out the following questionnaire, as it will enable us to better help you meet your legal, financial, and business needs.

All information you provide on following pages is confidential and privileged.

  • General Information

  • Education

  • ____________________
  • ____________________
  • ____________________
  • Professional Licenses

  • Insurance Information

  • Business Insurer

  • Worker’s Compensation Insurer

  • Malpractice/Business Insurer

  • Other Insurer

  • Professional Organizations

  • ____________________
  • ____________________
  • History of Disciplinary Problems

  • Description of Current Matter

    (Please provide a detailed description of your current case matter)
  • Parties to Litigation

    (Please list all parties to this litigation and your relationship to each)
  • History of Lawsuits

    (Please list year of case, names of plaintiff(s) and defendant(s), and include malpractice and criminal cases, if any)
  • Comments and Additional Information