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 85750

Map / Directions

Phone: (520) 909-0789

Weekends: By Appointment Only