Where To Turn When You’ve Been Wronged Home » Law Enforcement Intake Form Law Enforcement Intake Form Basic InformationTodays Date(Required) MM slash DD slash YYYY Your Full Name First Last Date of Birth(Required) MM slash DD slash YYYY Social Security Race Gender male female Marital Status single married divorced separated Drivers License Number or another form of ID State Contact InformationCurrent Address Current Address cont. Home TelephoneCell PhoneWork TelephoneEmail Address(Required) REFERRED TO OUR FIRM BY First Last Spouse/Significant Other InformationSpouse/Significant Other Name First Last Spouse AgeSpouse Race Number of Years TogetherSpouse Address if different Spouse Address if different cont. Spouse Telephone if differentSpouse Email Address Marriages/DivorcesSpouses Name | Date/Place of Marriage | How Marriage Terminated | Date/Place Filed Spouses Name | Date/Place of Marriage | How Marriage Terminated | Date/Place Filed Spouses Name | Date/Place of Marriage | How Marriage Terminated | Date/Place Filed Spouses Name | Date/Place of Marriage | How Marriage Terminated | Date/Place Filed Spouses Name | Date/Place of Marriage | How Marriage Terminated | Date/Place Filed ChildrenChild Name | Gender/Age | Living With | Name of Other Parent Child Name | Gender/Age | Living With | Name of Other Parent Child Name | Gender/Age | Living With | Name of Other Parent Child Name | Gender/Age | Living With | Name of Other Parent Child Name | Gender/Age | Living With | Name of Other Parent Child Name | Gender/Age | Living With | Name of Other Parent Educational HistorySchools Name | Dates Attended From/To | City/State | Degree Obtained Schools Name | Dates Attended From/To | City/State | Degree Obtained Schools Name | Dates Attended From/To | City/State | Degree Obtained Schools Name | Dates Attended From/To | City/State | Degree Obtained Schools Name | Dates Attended From/To | City/State | Degree Obtained Most Recent Emplyment HistoryBusiness Name | Position(s) Held | Dates Employed From/To | Reason for Leaving Business Name | Position(s) Held | Dates Employed From/To | Reason for Leaving Business Name | Position(s) Held | Dates Employed From/To | Reason for Leaving Business Name | Position(s) Held | Dates Employed From/To | Reason for Leaving Business Name | Position(s) Held | Dates Employed From/To | Reason for Leaving Information Regarding Your ClaimName of the individual agency or entity that you feel treated you wrongly Name of the individual agency or entity that you feel treated you wrongly Name of the individual agency or entity that you feel treated you wrongly Name of the individual agency or entity that you feel treated you wrongly Name of the individual agency or entity that you feel treated you wrongly What is the basis of your claim?What is the Basis of Your Claim? False Arrest Excessive Force Negligence Medical Negligence Selective Enforcement Malicious Prosecution Deliberate Indifference, Resulting in Serious Injury Other Civil Rights Violations Based on:Race If so List your race National Origin If so list your nationality Disability/Handicap (If so list your Disability/Handicap) Disability/Handicap (If so list your Disability/Handicap) cont. What was the date of the LAST Wrongful Action which you are basing you claim Where did you Wrongful Action take place 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?)Whom and why did you not proceed with them 1 Whom and why did you not proceed with them 2 Whom and why did you not proceed with them 3 Whom and why did you not proceed with them 4 Whom and why did you not proceed with them 5 Whom and why did you not proceed with them 6 Whom and why did you not proceed with them 7 IF CURRENTLY INCARCERATED, COMPLETE THE FOLLOWINGPlace of Incarceration Address Address cont. SPN or DOC Length of Sentence Date which current Incarceration began MM slash DD slash YYYY Schedule release date MM slash DD slash YYYY Offenses which you are being currently incarcerated 1 Offenses which you are being currently incarcerated 2 Offenses which you are being currently incarcerated 3 Do you anticipate being transferred from your current location to another facility? If so list that location if known During this period of incarceration, have you experience disciplinary actions? (If so, how many times & for what reason):If so how many times for what reason 1 If so how many times for what reason 2 If so how many times for what reason 3 CRIMINAL HISTORY SUMMARYOffense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow Offense | County/State | Year Occurred | SentenceRow OTHER GENERAL INFORMATIONAnswer 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? Yes No Have you otherwise sued anyone or been sued by anyone (except divorces)? Yes No Have you been diagnosed with a mental illness or disability? Yes No Have you ever been hospitalized or confined for a mental illness or disability? Yes No Have you ever been adjudicated incompetent? Yes No Do you suffer from serious physical illness or disability? Yes No Are you currently taking any prescription medications? Yes No Have you previously (during the period of your claim) taken prescription medication? Yes No Are you addicted to drugs or alcohol? Yes No Do you regularly use drugs or alcohol? Yes No Have you ever been treated for drug or alcohol abuse? Yes No Have you ever been rendered totally or partially disabled? Yes No Have you ever applied for disability compensation benefits? Yes No Have you ever been CONVICTED of a felony or misdemeanor? Yes No Have you ever served in the military? Yes No Have you ever filed bankruptcy? Yes No Have you ever filed a complaint or grievance with regard to any lawyer who provided legal services to you? Yes No Do you have any plan or intention to file bankruptcy? Yes No Have you ever hired a lawyer to represent you and terminated the lawyer’s services before representation was complete? Yes No 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.? Yes No Have you received treatment by any medical or mental health professional as a result of the action or occurrence which you are now complaining? Yes No 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? Yes No Are you currently an absconder or fugitive from any entity? Yes No 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 LISTUse 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.Witness 1 Name/Contact Info Group25 Friendly Hostile Neutral Witness 2 Name/Contact Info Group26 Friendly Hostile Neutral Witness 3 Name/Contact Info Group27 Friendly Hostile Neutral Witness 4 Name/Contact Info Group28 Friendly Hostile Neutral Witness 5 Name/Contact Info Group29 Friendly Hostile Neutral Witness 6 Name/Contact Info Group30 Friendly Hostile Neutral Witness 7 Name/Contact Info Group31 Friendly Hostile Neutral Witness 8 Name/Contact Info Group32 Friendly Hostile Neutral Witness 9 Name/Contact Info Group33 Friendly Hostile Neutral Witness 10 Name/Contact Info Group34 Friendly Hostile Neutral Witness 11 Name/Contact Info Group35 Friendly Hostile Neutral Witness 12 Name/Contact Info Group36 Friendly Hostile Neutral Witness 13 Name/Contact Info Group37 Friendly Hostile Neutral Witness 14 Name/Contact Info Group38 Friendly Hostile Neutral Witness 15 Name/Contact Info Group39 Friendly Hostile Neutral Witness 16 Name/Contact Info Group40 Friendly Hostile Neutral Witness 17 Name/Contact Info Group41 Friendly Hostile Neutral Witness 18 Name/Contact Info Group42 Friendly Hostile Neutral Witness 19 Name/Contact Info Group43 Friendly Hostile Neutral Witness 20 Name/Contact Info Group44 Friendly Hostile Neutral Witness 21 Name/Contact Info Group45 Friendly Hostile Neutral Witness 22 Name/Contact Info Group46 Friendly Hostile Neutral Witness 23 Name/Contact Info Group47 Friendly Hostile Neutral Witness 24 Name/Contact Info Group48 Friendly Hostile Neutral Witness 25 Name/Contact Info Group49 Friendly Hostile Neutral Witness 26 Name/Contact Info Group50 Friendly Hostile Neutral Witness 27 Name/Contact Info Group51 Friendly Hostile Neutral Witness 28 Name/Contact Info Group52 Friendly Hostile Neutral Witness 29 Name/Contact Info Group53 Friendly Hostile Neutral Witness 30 Name/Contact Info Group54 Friendly Hostile Neutral Folluw Up QuestionsIn your opinion, WHY do you think you were treated wrongfully?What action or comment, (if anything), did you, do which you think “might” have provoked the wrongful action taken against you?Have you personally witnessed others being subjected to the same wrongful action which you claim happened to you? If so, please describe.What damages do you believe you have suffered as a result of the wrongful action you are claiming in this intake? Please be specific regarding any wages you feel you may have lost, indebtedness you have incurred and/or physical, mental, or emotional injuries you believe you have suffered.What do you REALISTICALLY hope to achieve, receive, or gain from bringing a civil action against the party or parties who you feel treated you wrongfully? Please be specific.SIGNATURE(Required) First Last If you are done, add your signature to submitDATE MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
