Basic Information Your Full Name
Gender Marital Status Contact Information REFERRED TO OUR FIRM BY Spouse/Significant Other Information Spouse/Significant Other Name Marriages/Divorces Children Educational History Most Recent Emplyment History Information Regarding Your Claim What is the basis of your claim? What is the Basis of Your Claim? Civil Rights Violations Based on: Have you solicited the Representation of any other Attorney(s) in reference to this claim? (If so, whom and why did you not proceed with them?) IF CURRENTLY INCARCERATED, COMPLETE THE FOLLOWING During this period of incarceration, have you experience disciplinary actions? (If so, how many times & for what reason): CRIMINAL HISTORY SUMMARY OTHER GENERAL INFORMATION
Answer the following questions to the best of your ability. If your answer to ANY of these questions is YES, please explain on the prompt below.
Have you ever hired or consulted with a lawyer concerning this problem? Have you otherwise sued anyone or been sued by anyone (except divorces)? Have you been diagnosed with a mental illness or disability? Have you ever been hospitalized or confined for a mental illness or disability? Have you ever been adjudicated incompetent? Do you suffer from serious physical illness or disability? Are you currently taking any prescription medications? Have you previously (during the period of your claim) taken prescription medication? Are you addicted to drugs or alcohol? Do you regularly use drugs or alcohol? Have you ever been treated for drug or alcohol abuse? Have you ever been rendered totally or partially disabled? Have you ever applied for disability compensation benefits? Have you ever been CONVICTED of a felony or misdemeanor? Have you ever served in the military? Have you ever filed bankruptcy? Have you ever filed a complaint or grievance with regard to any lawyer who provided legal services to you? Do you have any plan or intention to file bankruptcy? Have you ever hired a lawyer to represent you and terminated the lawyer’s services before representation was complete? During the period in which you claim you were wronged, were there anyother stressful events in your life, such as births, deaths, divorces, marriages,significant problems with your children or family, criminal acts against you,etc.? Have you received treatment by any medical or mental health professional as a result of the action or occurrence which you are now complaining? Have you given any verbal, written or recorded statements to any person or entity regarding the issues which are the basis of this current complaint? Are you currently an absconder or fugitive from any entity? IF YOUR ANSWER TO ANY OF THE QUESTIONS ON THE PREVIOUS PAGE IS “YES,” PLEASE EXPLAIN IN THE AREA BELOW. IN THE SPACE PROVIDED BELOW, PLEASE DESCRIBE IN YOUR OWN WORDS (AND IN DETAIL) THE EVENTS THAT HAVE LED YOU TO BELIEVE THAT YOU WERE TREATED WRONGFULLY BY THE ENTITY OR ENTITIES YOU HAVE PREVIOUSLY IDENTIFIED. WITNESS LIST
Use this page to identify and describe any person(s) who have DIRECT knowledge regarding your claim(s). Include people which you deem to be either friendly to your claim, hostile to you or your claim or neutral. REMEMBER, THIS INFORMATION MAY PROVE TO BE VERY IMPORTANT TO YOUR CASE.
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