Intake Form

INTAKE FORM

Law Office of Scott A. Mossman
CONFIDENTIALITY POLICY

This intake form requests your personal information so that the Law Office of Scott A. Mossman (Attorney) can provide you with legal advice. Please give complete and accurate information so that Attorney can give you the correct advice. Your answers will be encrypted with RSA 2048 at the time of submission and only Attorney has the private key to unlock them (read more at https://www.jotform.com/security/).

Attorney treats the information as attorney-client privileged and confidential. Attorney will not disclose it unless ordered by an authority of competent jurisdiction or authorized by the person consulted. Attorney retains the information for a minimum of 7 years from completion of the consultation and any other legal services. Attorney does this in the event you seek further legal services or questions arise about the advice given.

Let Attorney know before submitting this form if you have any questions about how Attorney handles your confidential information.
You must confirm that you understand and agree to the above confidentiality policy to have a consultation with Attorney. You should cancel your appointment and not submit this form if you do not consent. Do you consent?
Do you authorize Attorney to share your confidential information with another attorney assisting you (such as your criminal defense attorney or another immigration attorney)?
Do you authorize Attorney to access court, law enforcement, immigration, and other records that may be available about you? Attorney may access these records online to prepare for your consultation.
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BIOGRAPHICAL INFORMATION

Provide information about the person who needs help.
Current Legal Name
Last, First Middle
Name on Birth Certificate (if Different From Current Legal Name)
Last, First Middle
Preferred Name/Nickname (if Different from Legal Name)
Other Names Used
Include aliases, names from prior marriages, etc.
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Place of Birth
City, State, Country
National/Citizen of
Current U.S. Immigration Status
Permanent resident, F-1, H-1B, L-1A, TPS, DACA, undocumented, etc.
Immigration File Number (A#)
Inmate Number(s)
Languages Spoken
PARENTS OF THE PERSON WHO NEEDS HELP

Please complete the names for conflict check purposes even if you do not think the person who needs help qualifies for immigration benefits through a parent.
Father’s Name
Last, First Middle
Father's Date of Birth

MonthDayYear
Date
Father's Place of Birth
City, State, Country
Father's U.S. Immigration Status
Citizen, permanent resident, undocumented, none/outside U.S., etc.
Mother’s Name
Last, First Middle
Mother's Date of Birth

MonthDayYear
Date
Mother's Place of Birth
City, State, Country
Mother's U.S. Immigration Status
Citizen, permanent resident, undocumented, none/outside U.S., etc.
GRANDPARENTS
Have any of the grandparents or great-grandparents of the person who needs help ever held U.S. citizenship (even if now deceased)?
MARRIAGE HISTORY/SPOUSE

Please complete the names for conflict check purposes even if you do not think the person who needs help qualifies for immigration benefits through marriage.
Total Number of Marriages of Person Who Needs Help
All marriages, including annulled marriages, religious marriages, and re-marrying a previous spouse.
Current Marital Status of the Person Who Needs Help:
Date of Current Marriage

MonthDayYear
Date
Place of Current Marriage
City, State, Country
Current Spouse or Partner's Name
Last, First Middle
Spouse or Partner's Other Names
Include name before marriage and aliases.
Spouse or Partner's Date of Birth

MonthDayYear
Date
Spouse or Partner’s Total Number of Marriages
All marriages, including annulled marriages, religious marriages, and re-marrying a previous spouse.
Spouse or Partner's Place of Birth
City, State, Country
Spouse or Partner's Current Immigration Status
Citizen, permanent resident, H-4, undocumented, etc.
Names Former Spouses of the Person Who Needs Help
Last, First Middle (give all names, including before, during, and after marriage)
CHILDREN

Include ALL children of the person who needs help. List additional children in the extra space below. Please complete the names for conflict check purposes even if you do not think the person who needs help qualifies for immigration benefits through a child.
Total Number of Children
All children, including adopted, step, and deceased children and children located inside or outside the U.S.
Provide the following information for each child, stepchild, adopted child, or deceased child.
Name: Date of Birth: Immigration Status: Name: Date of Birth: Immigration Status: Name: Date of Birth: Immigration Status: Name: Date of Birth: Immigration Status: Name: Date of Birth: Immigration Status: Name: Date of Birth: Immigration Status: Name: Date of Birth: Immigration Status: Name: Date of Birth: Immigration Status: Name: Date of Birth: Immigration Status: Name: Date of Birth: Immigration Status:

ENTRY/EXIT HISTORY
1. What is the date of the person's LAST entry into the United States?

MonthDayYear
Date
2. What was the person's immigration status at the time of the LAST entry?
Permanent resident, B1/B2 visitor, F1 student, H1B, L1A, advance parole, false documents, entered without inspection, etc.
3. Is the person currently a permanent resident or conditional permanent resident (a green card holder, 10- or 2-year)?
3.1. What is the date the person became a permanent resident or conditional resident (the "Resident Since" date on green card)?

MonthDayYear
Date
3.2. Did the person use Form I-485 to adjust to permanent resident status in the United States?
3.2.1. Provide the date of the LAST entry into the United States BEFORE approval of Form I-485 to adjust status.

MonthDayYear
Date
3.3. Has the person EVER remained outside of the U.S. for a continuous period of more than 180 days after receiving permanent resident status?
3.3.1. Provide the date the person returned to the U.S. after the absence of more than 180 days.

MonthDayYear
List additional entries after absences of more than 180 days in Continuation of Answers section at the end of the form.

CRIMINAL HISTORY SUPPLEMENT

List every incident where the person who needs help has been detained, cited, arrested, or charged for a crime or act of juvenile delinquency. You should include an incident even if no charges were filed, the charges were dismissed, or the case was later expunged, sealed, or destroyed. Be sure to include pending cases too. List additional incidents in the Continuation of Answers section at the end of the form.
First Offense
Date of Alleged Offense

MonthDayYear
Date
Place (City, State)
Alleged Crime(s)
Result
Second Offense
Date of Alleged Offense

MonthDayYear
Date
Place (City, State)
Alleged Crime(s)
Result
Third Offense
Date of Alleged Offense

MonthDayYear
Date
Place (City, State)
Alleged Crime(s)
Result

CONTINUATION OF ANSWERS
Use this section to provide more information about any of the previous answers.

SENDING THIS FORM TO THE ATTORNEY
Submit this form at least 2 business days before your appointment. Please be aware that submitting this intake form or attending a consultation does not mean that Attorney will represent the person who needs help or provide other legal services. Representation or any other legal service requires a signed agreement.
Click the Submit Form Button Only One Time.

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Should be Empty:

BIOGRAPHICAL INFORMATION

PARENTS OF THE PERSON WHO NEEDS HELP

GRANDPARENTS

MARRIAGE HISTORY/SPOUSE

CHILDREN

ENTRY/EXIT HISTORY

SCREENING QUESTIONS FOR BENEFITS

SCREENING FOR POTENTIAL ISSUES

CRIMINAL HISTORY SUPPLEMENT

First Offense

Second Offense

Third Offense

CONTINUATION OF ANSWERS

SENDING THIS FORM TO THE ATTORNEY