Home › Prospective Client Intake Form Prospective Client Intake Form "*" indicates required fields Step 1 of 6 16% X/TwitterThis field is for validation purposes and should be left unchanged.Thank you for choosing the CGA Law Firm. Please use this form to complete the client intake process prior to your consultation.Choose an area of Law*Bankruptcy & Debt RestructuringBusiness & CorporateEmploymentEstate Planning & AdministrationFamily LawGovernment & EducationLitigationReal EstateAcknowledgement of Notices* I acknowledge receipt of the “CGA Initial Consultation Policy,” the “Financial Arrangements with Clients” notice which governs payment of fees and costs including fees for the initial consultation, and the “Notice Concerning Privacy and Confidentiality of Information”. Disability Disclosure Check here if you require a disability-related accommodation in order to access legal services. Identify the requested accommodation: Client InformationName* First Last Married Check here if your spouse is also part of this matter Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Township/BoroughHome Phone NumberWork Phone NumberCell Phone NumberFax NumberEmail Preferred Method of Contact* Home Phone Work Phone Cell Phone Fax Email Please select which of the above contact methods you’d prefer we use to get in touch with youDate of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employment InformationEmployer Name*Employer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation* Spouse's InformationSpouse's Name* First Last Middle Initial Same Address?* Yes No Do you and you and your spouse share an address? Select one.Spouse's Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouse's Township/BoroughSpouse's Home Phone NumberSpouse's Work Phone NumberSpouse's Cell Phone NumberSpouse's Fax NumberSpouse's Email* Spouse's preferred method of contact* Home Work Cell Fax Email N/A, first spouse is primary contact Spouse's Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse's Employment InformationSpouse's Employer Name*Spouse's Employer Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouse's Occupation* How did you hear about CGA Law?Fill all that applyReferred by: Friend Relative Attorney Other Whom should we thank?How did you hear about us? Newspaper Internet/Website Event/Community Involvement Verizon Yellow Pages Other Other NewsletterNewsletter delivery method Check here to receive CGA newsletters and updates via mail Check here to receive CGA newsletters and updates via email Please choose the method through which you’d like to receive our newsletter Attorney-Client RelationshipAttorney-Client Relationship*Completion and submission of this Prospective Client Intake Form does not constitute establishment of an attorney-client relationship with CGA Law Firm or any of its attorneys. An attorney-client relationship is not established until the Prospective Client Intake Form is signed and returned, and the terms and scope of representation are agreed upon, including an agreement on legal fees and cost reimbursement. I have read and understand the above disclaimer.This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
