Intake Form

LEWIS LEGAL SERVICES, P.C.

INFORMATION INTAKE CONFIDENTIAL - OFFICE USE ONLY
YOUR NAME *

First Name Middle Name Last Name Suffix
Marital Status
SPOUSE NAME (if married)

First Name Middle Name Last Name Suffix
Your Email *
Spouse Email *
Mobile Phone Number *
Spouse Mobile Phone Number *
May we contact you by text? *

Yes No
May we contact your spouse by text? *

Yes No
Your Work Phone Number
Spouse Work Phone Number
Your Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your Mailing Address (if different from physical address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security No. *
Social Security No. (spouse) *
Birthdate *

Month Day Year
Date
Birthdate (spouse) *

Month Day Year
Date
Have you ever filed bankruptcy before? *

No Yes
What year(s) was your bankruptcy filed?
Has your spouse ever filed bankruptcy before? *

No Yes
What year(s) was your spouse's bankruptcy filed?
Have you gone by any other name in the last 8 years? (Maiden name, nickname, etc) *

No Yes
If yes, please list all names, separated by commas.
Has your spouse gone by any other name in the last 8 years? (Maiden name, nickname, etc) *

No Yes
If yes, please list all your spouse's names, separated by commas.
How did you hear about our office?

Direct Mailing Google Search Referral (friend, family, co-worker, lawyer) Advertising Facebook / Avvo / Manta
Any specific questions or concerns that you would like answered or discussed?
Should be Empty:

LEWIS LEGAL SERVICES, P.C.