Full Name (include middle) *

Email Address

Phone (best)

Phone (work)

Phone (cell)

Best Time to Call

Birth Date

Social Security Number

Explain Your Immigration Status

(max 150 characters)

Are you a U.S. Citizen?

Yes

No

Do you have a green card?

Yes

No

Do you have a work Visa?

Yes

No

Current Address

City

State

Zip

From When?

Living with Who?

Last Year Completed

Degrees Received

High School

College

Do you suffer from any diagnosed mental illness?

Yes

No

What is the official diagnosis?

Are you currently being treated?

Yes

No

Name of Mental Health Professional

Do you have any disabilities?

Yes

No

What is the official diagnosis?

Are you taking any prescription medication?

Yes

No

If yes, what medications?

Position

Supervisors Name

Employer

Years Employed

Employer Address

Employer City

State

Zip

Date Started

Days

Hours

Wages

Business Phone

Supervisors Phone

Supervisors Email

Date of Incident

Charges Filed

(max 75 characters)

Police Department

Were you arrested?

Yes

No

Arrest Date

How many days in jail?

Release Date

What happened?

(max 400 characters)

Explain arrest details?

(max 400 characters)

List witnesses / what they saw?

(max 400 characters)

Did you post bail/bond?

Yes

No

Amount

Bail Company

Amount You Paid

Any no-contact orders?

Yes

No

With Who

Relationship

Do you have a drug or alcohol restrictions or monitoring?

Yes

No

Describe

Other Release Conditions

(max 75 characters)

Do you have any outstanding warrants anywhere?

Yes

No

If yes, what counties?

Describe

(max 100 characters)

Next Court Date

Time

Court Address

Charges

(max 30 characters)

Date of Conviction

Sentenced?

Yes

No

Days Served

Probation?

Yes

No

Years of Probation

When Discharged

Any Violations?

(max 30 characters)

Charges

(max 30 characters)

Date of Conviction

Sentenced?

Yes

No

Days Served

Probation?

Yes

No

Years of Probation

When Discharged

Any Violations?

(max 30 characters)

Charges

Date of Conviction

Sentenced?

Yes

No

Days Served

Probation?

Yes

No

Years of Probation

When Discharged

Any Violations?

(max 30 characters)

Charges

Date of Conviction

Sentenced?

Yes

No

Days Served

Probation?

Yes

No

Years of Probation

When Discharged

Any Violations?

(max 30 characters)

I understand that I will be charged for my initial consultation and that payment will be due at the end of the appointment at the attorney’s hourly rate.