Contact Us

General Intake Questionnaire

It Is Important That You Answer Each Question Completely and Truthfully

Full Name: Phone Number:

OK to Text?

Yes No

Email Address: Mailing Address: Spouse / Partners Name: Date of Marriage Names: Previous Marriage: Names and Ages of Children: Ever Been Convicted of a Felony? Potential Conflict CheckOpposing Party Name (s): Relationship to Opposing Party: Matter Details

Type of Case:

Personal Injury / Car Accident Malpractice Consumer Fraud / Protection Other

If Other, Specify: Date of Incident / Loss: (Crucial for Determining Statute of Limitations) Location, City and State of Incident: Brief Summary of the Claim: (If Automobile Accident Claim):Anyone Cited? Damage to Vehicles: Pictures Taken? Anyone Admit Fault: What Facility for First Medical Treatment: Names and Addresses of All Medical Providers and Specialty Do You Have Automobile Insurance? What Company? Policy Number: Extent of Coverage: Do You Have a Copy of the Declaration Page? Other Parties Insurance?

Are You on Social Media?

Yes No

If So, What Web Sites and Your Name on Each Site: Briefly Explain What Is Your Desired Outcome? Any Other Information You Would Like To Provide:

ALL THE INFORMATION LISTED ABOVE IS TRUE TO MY KNOWLEDGE AND BELIEF

Our Office

Address

Tucson, AZ 85711

Map / Directions

Phone: (520) 909-0789

Weekends: By Appointment Only