Law Firm Client Intake Form

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.

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

Name Phone Number

Marital Status:
Married Single Divorced Widowed Separated

Drivers License # Social Security #

Are you known by any other names? Yes No

E-Mail

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:

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?

Are there deadlines/statutes of limitations?

Yes No

Your Determination of the Date of Incident:

Source Relied On:

Verified on insurance or police report: Yes 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:

Is Matter Subject to Kansas 90-Day Service Statute?

Yes No

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:

Related Parties (Screen for Potential Conflicts of interest)

Sign Now