Third Party Intake Form

If you are seeking legal advice for someone other than yourself, please provide the following information for the person who needs legal advice:


The Other Person’s Name *:
The Other Person’s Address *:
The Other Person’s City *:       State:       Zip:
The Other Person’s County: *
Your Phone *:
An Alternate Phone for You:
Email:
What is the best time of day to reach you by telephone?
Date of Birth *: (xx/xx/xxxx)
This person's ethnicity *:
Sex *: Female     Male
Marital Status:
Citizenship:
Are they disabled? Yes     No
Are they a veteran? Yes     No
Does this person receive Medicare? Yes     No
How many people live in their home?
Monthly income range for the person seeking assistance:
Your relationship to this person:
Your name *:
Has this person given you a power of attorney to act on their behalf? Yes     No
Are you this person’s court appointed guardian? Yes     No
Is there a reason this person cannot contact us directly? Yes     No
If yes, please explain:
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Briefly describe your legal problem:
limit 800 characters
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