Client Intake Form

Name:

Date:

Address:

Date of Birth:

Address:

City: State: Zip:

E-Mail:

SSN:

Phone:

Alt - Phone:

Race:

Sex:

Age:

Please enter a number from 1 to 120.

Marital Status:

Whom may we thank for your referral?

Table of Contents

PEOPLE THAT WILL ALWAYS KNOW HOW TO CONTACT YOU:

Name of Closest Relative:

Phone

Relationship:

Address:

Name:

Phone

Address:

Relationship:

Name:

Phone

Address:

Relationship:

EDUCATION

Highest Grade Completed:

College:

Vocational School:

EMPLOYMENT AND MILITARY HISTORY

Present Employer:

How Long:

Address:

Job Description:

Salary:

Supervisor:

Phone

May we call you at work?

Prior Employers:

Military History:

MEDICAL HISTORY

Have you ever been diagnosed or treated for any alcohol or drug addiction issues? If so where were you treated and what were you treated for?

Have you had any psychiatric examinations before this incident?

Have you had any chronic health problems? If so, list them below:

Did you use any medication regularly before this incident? If so, list the type and the reason:

CIRCUMSTANCES OF ARREST

Describe (Date, Time and Place, etc…)

Description (Continued)

Witness Name(s) and address, if known:

OTHER PERSON(S) ARRESTED:

Name:

Attorney (if known):

Name:

Attorney (if known):

Name:

Attorney (if known):

PROBATION OR PAROLE STATUS

Are you on probation or parole?

If yes, Probation Officer:

County:

Charges:

Suspended Sentence:

PRIOR CRIMINAL RECORD (INCLUDING JUVENILE RECORD)

County + Charge:

Date:

Sentence:

County + Charge:

Date:

Sentence:

County + Charge:

Date:

Sentence:

Charge:

Date:

Sentence:

DISCLOSURE

Please list all persons authorized to receive information pertaining to your case, write “none” if none:

Name:

Phone:

Address

Address:

Relationship:

Name:

Phone:

Address

Address:

Relationship:

ATTORNEY NOTES

COURT DATES:

POTENTIAL DEFENSE WITNESSES:

Name:

Phone:

Relationship:

Name:

Phone:

Relationship:

Name:

Phone:

Relationship:

DOCUMENTS THAT NEED TO BE OBTAINED

NARRATIVE:

INITIAL CONSULTATION AGREEMENT

Please note that our first meeting is an initial consultation only. It does not establish an attorney- client relationship between The Law Office of Victor Nasser and you.
All information provided to the firm by you as part of this packet and at the Initial Consultation is protected by the Attorney Client Privilege. Please understand, however, that by meeting with you to discuss your legal concerns, The Law Office of Victor Nasser has not undertaken your representation. Meeting with the firm for an Initial Consultation does not bind this firm or the potential client (you) in any way to provide further work or legal services.
Should this firm undertake your representation, our arrangement must be formalized in writing and consideration must be paid for our services beyond the cost of the Initial Consultation.
Essentially, the Initial Consultation is an opportunity for the firm to meet you and gather information about your legal concerns. It is also an opportunity for you and the firm to determine whether we are likely to have a strong, productive working relationship.
The Initial Consultation lasts approximately one (1) hour. The cost for this consultation is $____0______. Payment is due at the end of our meeting by cash, check, or major credit card.
Criminal Law litigation is often an emotionally and financially draining process. It can also be lengthy and exhausting. Therefore, it is critical for the client, attorney, and the attorney’s staff (if any) to work well together. The Law Office of Victor Nasser realizes there are situations where the firm is not the right fit for a potential client. Therefore, that the firm retains the right to refuse to take on a matter, just as you, the potential client, retain the right to decide not to retain the firm.
Thus, by signing this agreement, you acknowledge that this Initial Consultation is limited in scope and purpose, and does not require this firm to enter into a retainer agreement with you.
By your signature below, you acknowledge that you have read this entire document, and agree and understand the limited nature of the Initial Consultation, as well as its cost. Thank you for considering The Law Office of Victor Nasser.

I acknowledge that I have read, understand and agree to the statements above.

Name (please print)

Date

SIGNATURE

Client Intake Form

PEOPLE THAT WILL ALWAYS KNOW HOW TO CONTACT YOU:

EDUCATION

EMPLOYMENT AND MILITARY HISTORY

MEDICAL HISTORY

CIRCUMSTANCES OF ARREST

OTHER PERSON(S) ARRESTED:

PROBATION OR PAROLE STATUS

PRIOR CRIMINAL RECORD (INCLUDING JUVENILE RECORD)

DISCLOSURE

ATTORNEY NOTES

POTENTIAL DEFENSE WITNESSES:

DOCUMENTS THAT NEED TO BE OBTAINED

INITIAL CONSULTATION AGREEMENT

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Victor Nasser

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