Prospective Client Intake Form

Prospective Client Intake Form

Share details about your situation so our office can review and recommend next steps.
About You
First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County of Residence
Preferred Contact Method
Legal Help Sought
Conflict Check
List all adverse or opposing parties
Other names connected to the matter
Divorce & Family Law
Matter Type
Has a court case already been filed?
County Where the Case Is Filed
Date of Next Court Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is either party currently represented by an attorney?
Brief description of what is happening and what help you want
Estate Planning
What are you interested in?
What best describes you?
Do you currently have any estate-planning documents?
Please share any particular concern or goal we should address.
Personal Injury
Injury matter type
Date of incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where the incident occurred

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Brief description of what happened
What injuries were suffered
Medical treatment received
Treatment ongoing
Incident reported to police, animal control, business, property owner, or insurance company
Currently represented by another attorney for this injury
Final Questions
Are there any urgent deadlines, court dates, hearings, or other important dates we should know about?
If yes, what is the date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If yes, please briefly explain the deadline or event.
How did you hear about Joerika Stitt Esquire, LLC?
Anything else you would like the firm to know?
Submission disclaimer: Joerika Stitt Esquire, LLC has not agreed to represent you. An attorney-client relationship begins only after the firm accepts the matter and a written engagement agreement is signed.
Should be Empty:

Prospective Client Intake Form

About You

Conflict Check

Divorce & Family Law

Estate Planning

Personal Injury

Final Questions