New Client Intake
Thank you for choosing to complete this form in advance! If you have any questions about how to complete the form, please contact the person who scheduled your appointment.
Date of Consultation Meeting
-
Month
-
Day
Year
Date
Attorney
Amy E. Dougherty
Mary Ellis Patton
Katie E. Finnell
I'm not sure
How did you hear about us?
Internet
TOPS in Lex
Senior Center Newsletter
Referral
Other
Client 1 information
If you are part of a married couple, please complete this section for one of you. There will be an additional section for a spouse.
Full Name (please include middle and maiden names if applicable)
*
Do you have a nickname or something other than your legal name that you go by? (if not, leave blank)
Email
example@example.com
Do you have an additional email address?
Yes
No
Secondary Email
example@example.com
Phone Number
Please enter a valid phone number.
Do you have an additional phone number?
Yes
No
Secondary Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Are you a US citizen?
Yes
No
Are you a veteran?
Yes
No
What were your dates of service?
Are you currently employed?
Yes
No
I am retired
What is your current occupation?
What was your occupation prior to retirement?
Are you currently married?
Yes
No
What is your date of marriage? (year is sufficient)
Do you have a pre/post-nuptial agreement?
Yes
No
Have you had any previous marriages?
Yes
No
How many previous marriages have you had and how did they end? (divorce, death, annulment)
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Client 2 Information
Full Name (please include middle and maiden names if applicable)
Do you have a nickname or something other than your legal name that you go by? (if not, leave blank)
Is your address the same as client 1?
Yes
No
Client 2 address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Do you have an additional email address?
Yes
No
Secondary Email
example@example.com
Phone Number
Please enter a valid phone number.
Do you have an additional phone number?
Yes
No
Secondary Phone Number
Please enter a valid phone number.
Are you a US citizen?
Yes
No
Are you a veteran?
Yes
No
What were your dates of service?
Are you currently married?
Yes
No
What was your date of marriage? (year is sufficient)
Did you have a pre/post-nuptial agreement?
Yes
No
Have you had any previous marriages?
Yes
No
How many previous marriages have you had and how did they end? (divorce, death, annulment)
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Next
Primary contact information
Who should we contact with questions?
Client or client spouse
Other
Name of primary contact
Relationship to client
Child
Parent
Sibling
Friend
Other
Is primary contact's address the same as the client's?
Yes
No
Primary Contact's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
What is your preferred method of contact?
Email
Phone
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Next-of-Kin
Please list your children or if none, then next-of-kin other than your spouse. This does not mean these are people who will necessarily be named as beneficiaries in your will.
Do you have any children?
Yes
No
Child 1 full name
Child 1 date of birth
-
Month
-
Day
Year
Date
Is Child 1 disabled/do they receive government benefits?
Yes
No
Child 1 address
If you do not know their full address, city and state is sufficient.
Child 1's children's names and ages (if applicable)
If you do not know an exact age, please estimate or indicate if they are over or under 18
Add a second child?
Yes
No
Child 2 full name
Child 2 date of birth
-
Month
-
Day
Year
Date
Is Child 2 disabled/do they receive government benefits?
Yes
No
Child 2 address
If you do not know their full address, city and state is sufficient.
Child 2's children's names and ages (if applicable)
If you do not know an exact age, please estimate or indicate if they are over or under 18
Add a third child?
Yes
No
Child 3 full name
Child 3 date of birth
-
Month
-
Day
Year
Date
Child 3 address
If you do not know their full address, city and state is sufficient.
Is Child 3 disabled/do they receive government benefits?
Yes
No
Child 3's children's names and ages (if applicable)
If you do not know an exact age, please estimate or indicate if they are over or under 18
Add a fourth child?
Yes
No
Child 4 full name
Child 4 date of birth
-
Month
-
Day
Year
Date
Child 4 address
If you do not know their full address, city and state is sufficient.
Is Child 4 disabled/do they receive government benefits?
Yes
No
Child 4's children's names and ages (if applicable)
If you do not know an exact age, please estimate or indicate if they are over or under 18
Add additional children?
Yes
No
Please provide information for any additional children here:
Do you have any living parents?
Yes
No
Please list your parents' full names, dates of birth, and cities/states of residence.
Do you have any siblings?
Yes
No
Please list your siblings' full names, dates of birth, and cities/states of residence.
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