CLIENT INTAKE FORM

YOUR PERSONAL INFORMATION:

Date you completed this form: _____________

Full Name: ____________________________________________

First Middle Last

Place and Date of Birth:_______________________

Social Security No.: _______________

Full Home Address:

________________________________________________________

Work Phone: ______________________ Home Phone: _______________________

Fax Number: ______________________ Cell Number: _______________________

Email address: ___________________________________________________________

INFORMATION ABOUT YOUR EMPLOYMENT:

Name of Employer: _________________________________________________________

Employment Address:

_________________________________________________________

Job Title: _______________________ Nature of Job: ____________________________

Employed since: _________________ Number of Employees: _____________________

Average Number of Hours Worked Per Week: ____________________

Please know that email communication can be intercepted by others and is, therefore,

not always confidential. Be very careful about how you communicate with your attorney via email.

Please give a brief description of the reason you have consulted this firm.

________________________________________________________________________

Dated:________________ Signature:______________________________