Foreclosure Intake Form
Client First Name
*
Client Last Name
*
Client Middle or Maiden Name
Client Address
Client Address Line 2
City of Client Address
State of Client Address
Zip Code of Client Address
Email Address
*
Phone Number
*
First Name of Spouse
Last Name of Spouse
Middle or Maiden Name of Spouse
Address of Spouse
Address Line 2 of Spouse
City of Address of Spouse
State of Address of Spouse
Zip Code of Address of Spouse
Phone Number of Spouse
Dependants
List all legal dependents and indicate whether they live in your household.
What is the number of people living in your household?
1
2
3
4
5
6
First and Last Name of Dependent 1
Relationship to Dependent 1
Does Dependent 1 Live with You?
Yes
No
First and Last Name of Dependent 2
Relationship to Dependent 2
Does Dependent 2 Live with You?
Yes
No
First and Last Name of Dependent 3
Relationship to Dependent 3
Does Dependent 3 Live with You?
Yes
No
First and Last Name of Dependent 4
Relationship to Dependent 4
Does Dependent 4 Live with You?
Yes
No
Briefly explain what you may need advice about or assistance with today
Are there any parties involved? (Examples: a friend, an employer, a neighbor, signor of a contract, etc. This should include parties on either side of your issue and their relationship)
List the documents (papers) that you think may help us to understand the issues.
(NOTE: Any documents you supply that are important to your matter will be photocopied, with your permission, and your originals returned to you at the conclusion of the initial interview.)
Ideally, if things turn out precisely the way you want, what would the outcome be?
Knowing that there are no guarantees, what can you accept?
Please classify your urgency in concluding this matter? (check one)
Critical | Personal safety or continuation of business depends on it.
Very important | severe hardship, personal or financial inconvenience if matter is not resolved quickly.
Important | Matter interferes with business or personal financial stability.
Needs to be done, but no immediate hardship in the interim.
Just thought I'd see if it was worth perusing, but I'm not counting on anything.
Just wanted to know what my rights are? I'll then let you know after I think about it.
If the matter involves payment of money you feel you are owed, how long can you wait before not getting paid?
Days
Weeks
Months
Years
Are we the first attorneys you have consulted regarding this matter?
Yes
No
If no, why did you not hire their services?
Have you ever been represented by an attorney before?
Yes
No
If yes, please state the circumstances
How will you pay for your attorney's fees in this matter?
Check Today
Cash Today
Contingency Fee
On Account
Credit Card
Credit Card Number
Expiration Date
Marital Status
Married
Single
Divorced
Widowed
Seperated
Drivers License Number
Social Security Number
Are you known by any other names?
Yes
No
What names?
(A fictitious name, a nickname, a former name, your maiden name etc.)
Where are you employed?
Address of Employer
Address Line 2 of Employer
City of Address of Employer
State of Address of Employer
Zip Code of Address of Employer
Occupation
Work Phone Number
May we contact you there?
Yes
No
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.
What is their relationship to you?
Address of Your Contact
Address Line 2 of Your Contact
City of Address of Your Contact
State of Address of Your Contact
Zip Code of Address of Your Contact
Phone Number of Contact
How did you learn about our office?
A Friend
Yellow Pages
Bar Referral
Our Webpage
Former Client
Other
Additional information you would like to tell us