We are safely open. Please reach out to us remotely before coming to our office so that we can safely communicate. We appreciate your patience.

Linkedin-in Facebook-f

Where To Turn When You’ve Been Wronged

Contact Marie A. Mattox, P.A.

While this website provides general information, it does not constitute legal advice. The best way to get guidance on your specific legal issue is to contact a lawyer. To schedule a meeting with an attorney, please call the firm or complete the intake form below.

Law Enforcement Intake Form

Basic Information

MM slash DD slash YYYY
Your Full Name
MM slash DD slash YYYY
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

MM slash DD slash YYYY
MM slash DD slash YYYY

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?

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.
Group25
Group26
Group27
Group28
Group29
Group30
Group31
Group32
Group33
Group34
Group35
Group36
Group37
Group38
Group39
Group40
Group41
Group42
Group43
Group44
Group45
Group46
Group47
Group48
Group49
Group50
Group51
Group52
Group53
Group54

Folluw Up Questions

SIGNATURE(Required)
If you are done, add your signature to submit
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

Please Use the Buttons Below to Fill Out an Online Form That Will Auto Fill a PDF File That Gets Sent to US

EMPLOYMENT INTAKE FORM
LAW ENFORCEMENT INTAKE FORM
PERSONAL INJURY INTAKE FORM