Client Intake Form

Client Intake Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*

MaleFemale
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Preferred Method of Contact*

PhoneEmailText Message

Home Address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Legal Information
Do You Currently Have Any Ongoing Legal Cases?*

YesNo
If Yes, Please Provide a Brief Description:
(Include case type, jurisdiction, and any upcoming court dates.)
What Type of Legal Assistance Do You Need?*

Family LawCriminal DefenseHousing IssuesOther
Have You Previously Represented Yourself in Court?*

YesNo
If Yes, Please Provide Details of Your Experience:

Life Support Needs
Do You Need Assistance with Any of the Following?*

HousingEmploymentFinancial SupportCounseling/Emotional SupportOther
Please Describe Your Current Situation:*
(Include any challenges you're facing that we may be able to assist with.)

Religious Affiliation
Are You Affiliated with Any Religious Beliefs or Organizations?*

YesNo
If Yes, Please Specify:*
(Optional: Provide details if it influences the type of support you're seeking.)

Additional Information
How Did You Hear About Us?*
Is There Any Other Information You Would Like Us to Know?*
What Are Your Primary Goals in Seeking Our Services?*

Consent and Agreement
I Consent to the Collection and Use of My Personal Information as Described in the Privacy Policy*

YesNo
I Acknowledge That A Force 2 Reckoned With Is Not Providing Legal Representation, but Rather Support and Guidance.*

YesNo
Signature*

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