Law Firm Client Intake Form – Fill Out and Use This PDF

WARNING AND DISCLAIMER: The information herein was prepared by The Bar Plan Mutual Insurance Company for general information purposes, and should not be construed as legal advice or legal opinion with regard to any specific circumstance or set of facts. The reader must conduct independent research and analysis to determine all possible and appropriate legal and ethical issues that might apply to a specific situation and the best way to address these issues in the jurisdiction where

the reader is located.

Sample Law Firm Intake Form

Please note: This form should be modified to meet the facts of the individual case.

Client Contact Information

Name: ____________________________________________________________

Address:

__________________________________________________________________

Home Phone: _________________________________________

Cell Phone: __________________________________________

Work: _______________________________________________

Emergency Contact

__________________________________________________________

NamePhone Number

Marital Status:

[ ] Married [ ] Single [ ] Divorced [ ] Widowed [ ] Separated

Drivers License # ________________________Social Security #____ __ ____

Are you known by any other names? [ ] Yes [ ] No If yes name(s)

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E-Mail

Many e-mail attorney-client communications involve relatively innocuous information and do not present a great concern even if they are intercepted. On the other hand, any communication from an attorney that can be accessed by others may be of concern in some situations. Please think carefully about your email process. Do other persons, who are not parties to this matter, have access to the email? For example, if e-mailing from home, does your spouse or other family also have access to the computer and e-mail program? If e-mailing from work, does your company reserve the right to view all e-mail traffic on their servers? By and large, most do. Any unprotected access to our e-mail communications may raise issues of whether the attorney-client privilege was waived, and if so, the communication may be available for review and use by the adverse party.

Anytime you communicate with your attorney, include only the attorney in the communication. DO NOT “cc” other parties to the action, adverse counsel, judges, family, friends, relatives, or ANYONE else.

Where is the computer you use for e-mail: ________________________________

Does anyone else use or have the ability to use that computer: ________________

Is that computer connected to a network: _________________________________

E-mail Address: ____________________________________________________

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Where are you currently employed?

__________________________________________

May we contact you there? __________________________

If your mail is returned as undeliverable or telephone service terminated, please provide the name of someone (friend or relative) you believe will always know how to contact you.

Name:_____________________________________________________________

Relationship:_______________________________________________________

Address:

__________________________________________________________________

__________________________________________________________________

Phone No. (____) ______________

Briefly describe the type of legal matter for which you are seeking consultation:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________

What are your goals for this representation?

________________________________________________________________________

____________________________________________________________

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Are there deadlines/statutes of limitations?

_XX__ Yes ____ No (If No, please describe why not)____________________

If yes, please review the following:

Your Determination of the Date of Incident: _________10/22/2011________

Month	Day
Year

Source Relied On _____Client Intake Interview_________________________

Verified on insurance or police report: Yes _XXX___ No______

Jurisdiction: Missouri Other

Statute of limitations:__________________________________________

REMINDER- REVIEW APPLICABLE STATUTE OF LIMITATIONS

Attach Copy of Applicable Statute to This Form

Applicable deadline based upon date of the incident: ___________

Calculation Reviewed By: _________________________

•All deadline calculations should be reviewed and confirmed by another attorney in the firm

Date Calendared BY: ___________________

Date Calendared WHEN: ______________________________

Calendared Date Confirmed BY: _________

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Is Matter Subject to Kansas 90-Day Service Statute?

__XX__ Yes ____ No (If No, please describe why not)

______________________________

Date Matter Filed: __________

Date 90-Day Deadline Calendared: ___________

Calendared By: ________________

Calendared Date Confirmed By: __________

Date Service Obtained:

________________________________________________________________

Does Client Have a Social Media Page (Facebook, Twitter, Blog)

Yes:__________

No:__________

Information currently on your social media site may potentially have an impact on your case, either positively or negatively. Information you place on your social media site in the future may also potentially affect your case. Generally, it is advisable NOT to discuss the merits or details, the opposing party, counsel, judge, witnesses, etc., of your case in any open forum. NEVER discuss with ANYONE, or disclose in any manner, discussions we have with you regarding your case, whether on a social media site or any setting. Please review your social media sites promptly. If you have any questions regarding how a prior entry or posting may potentially affect your case, please feel free to discuss the issue with us.

Opposing Party

Name:____________________________________________________________

Relationship to Client: ______________________________________________

Additional Information:____________________________________________

__________________________________________________________________

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Related Parties (Screen for Potential Conflicts of interest)

Name:__________________________ Relationship:_____________________

Name:__________________________ Relationship:_____________________

Name:__________________________ Relationship:_____________________

Name:__________________________ Relationship:_____________________

Name:__________________________ Relationship:_____________________

Name:__________________________ Relationship:_____________________

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