POTENTIAL CLIENT FORM

POTENTIAL CLIENT FORM

**ALL INFORMATION PROVIDED IS STRICTLY CONFIDENTIAL**
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
E-mail
Were you referred by anyone?
If yes, by who?
Opposing Party (Employer):
If employment related, please answer the following.
Position:
Length of employment:
If you are no longer employed, please provide the date of separation:

MonthDayYear
Type of pay:
Number of hours worked per week:
Were/are you paid overtime?
Did/do you have the ability to hire/fire others?
If you are no longer employed, did you file for unemployment?
Did you receive unemployment benefits?
Please provide a brief description of why you feel you are in need of an attorney:

0/400
**THE COST FOR A ONE HOUR CONSULTATION RANGES FROM $225 - $350**

**THE INFORMATION PRESENTED AT THIS SITE SHOULD NOT BE CONSTRUED TO BE FORMAL LEGAL ADVICE NOR THE FORMATION OF A LAWYER/CLIENT RELATIONSHIP**
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