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Full Name *

Email Address *

Zip Code *

Phone Number *

Type of Case *Type of CasePersonal Injury LawCar Accident LawCriminal LawDivorce and Family LawBankruptcy LawEmployment LawImmigration LawMedical Malpractice LawReal Estate Law

Date of Injury

Injury TypeSlip & FallVehicle AccidentWorkplace InjuryDog BiteProduct Liability (Defective Product)Construction Site AccidentPedestrian AccidentAssault or Physical AttackNursing Home AbuseOther

Type of VehicleCarBikeTruck

Please Specify

Location of Injury

Severity of InjuryMinorModerateSevere

Did you seek medical attention?YesNo

Witness Information

Date of Accident

Were you Injured?YesNo

Police Report Filed?YesNo

Location of Accident

Insurance Provider

Severity of InjuriesMinorModerateSevere

Date of Arrest

ChargesTheftAssaultDrug PossessionDUI / DWIDomestic ViolenceFraudBurglaryHomicide / ManslaughterSexual OffenseVandalismProbation ViolationGun PossessionTrespassingResisting ArrestOther

Please Specify

Have you been to Court?YesNo

Bond Amount

Do you need Bail Assistance?YesNo

Were there any Witnesses?YesNo

Date / Time

Children Involved?YesNo

Do you want full custody?YesNo

Do you have a prenup?YesNo

Have you filed for divorce?YesNo

Partner's Current Location

Date of Filing

Type of BankruptcyChapter 7Chapter 13

Have you consulted a bankruptcy attorney before?YesNo

Total Debt Amount

Income Source

Date of Incident

Type of DisputeDiscriminationHarassmentWage Theft / Unpaid WagesWrongful TerminationWorkplace RetaliationUnsafe Working ConditionsOvertime DisputesDenied Leave (FMLA or Medical)Contract ViolationOther

Please specify

Did you report the issue to HR?YesNo

Are you currently Terminated/Suspended?YesNo

Type of Employment Full-timePart-timeFreelance

Date of Immigration Filing

Visa TypeH1B (Work Visa)F1 (Student Visa)Green Card (Permanent Resident)Tourist Visa (B1/B2)Asylum ApplicationDACACitizenship/NaturalizationSpouse/Marriage Visa (K1/K3)Employment-Based Green CardFamily-Based ImmigrationOther

Please Specify

Current Immigration StatusPendingApprovedDenied

Have you been denied entry before?YesNo

Are you seeking asylum?YesNo

Date of Treatment

Type of Medical MalpracticeMisdiagnosisDelayed DiagnosisSurgical ErrorAnesthesia ErrorBirth InjuryMedication ErrorHospital NegligenceInadequate Follow-UpFailure to TreatEmergency Room ErrorNursing Home NegligenceWrong-Site SurgeryLab Result ErrorConsent Not Taken ProperlyOther

Please Specify

Injuries Sustained

Have you consulted another doctor?YesNo

Was the malpractice reported?YesNo

Date of Property Transaction

Type of DisputeLease DisputeProperty Sale IssueZoning or Land Use ProblemEviction MatterBoundary DisputeTitle or Ownership ConflictProperty Damage ClaimConstruction DefectForeclosure AssistanceOther

Please Specify

Are you a Tenant or Property Owner?TenantProperty Owner

Is there a contract in dispute?YesNo

Are you seeking compensation?YesNo

Additional Information

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