Consultation Information
CLIENT INFORMATION
Full Name (*)
Please provide the full name of the person who will be the client
Email address (*)
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Drivers License No. & State
Date of Birth & Current Age
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Best Time to Contact & Where (*)
Please advise of when, where and how to contact you
Emergency Contact Name, Phone & Relationship
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Residence Information
Residence Street Address
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City/State/ZIP Code
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Home Phone Number
Cell Phone Number
Home Email Address
Please provide a valid email address to contact you
Employment Information
Employer Name
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Work Phone Number
Work Email Address
Job Title & Description
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Length of Employment
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Annual Salary or Hourly Wage
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Legal Assistance Information
Nature of Legal Assistance Needed (*)
Please explain how we may help and the legal services you need
Referred By?
Name of Your Current or Former Attorney
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OPPOSING PARTY / ADVERSARY INFORMATION
Full Name (*)
Please provide the full name of the opposing party
Relationship to Client (*)
How do you know the opposing party? Specify any relationship, e.g., former girlfriend, spouse, etc.
OPPOSING COUNSEL
Name of Attorney
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Street Address
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City/State/ZIP Code
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Phone/Fax/Email
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COURT PROCEEDINGS
Is a Case Pending?
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When Was Case Filed & Who Started It?
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Nature of Proceedings
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Your Status in the Case
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Name of Court
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Case Number
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Is a Court Hearing Scheduled?
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When is the Hearing Scheduled?
(date & time)
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What is the Hearing About?
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LEGAL SERVICES PAYMENT INFORMATION
Full Name of Person Responsible for Payment
Complete Information Below if Someone Other Than Client is Responsible
for Payment of Legal Services
Residence Street Address
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City/State/ZIP Code
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Social Security Number
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Date of Birth
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Phone Number
Drivers License Number & State
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Bank Name & Address
Payment for legal services is due when provided. Legal services include attorney and/or
paralegal time expended on your case or matter, court filing fees, postage, photocopying, fax
transmissions, online legal research costs and costs of investigation which may include,
without limitation, police reports, criminal record, credit record and driver license checks.

Martin Law Firm (Brett W. Martin, P.C.) may advance certain expenses during the course of
working on your case. Reimbursement of expenses is required at the time they are billed. In the
event payment of legal services is not made in full within 10 days of the billing date, interest is
charged on your account at the rate of 18% per year, compounded monthly. Such matters are
explained in further detail in the retainer agreement involving your case.

By submitting this intake form you are indicating that the information provided above and on the
foregoing pages are correct and accurate to the best of your knowledge, and you are authorizing
Martin Law Firm (Brett W. Martin, P.C.) to conduct a credit record check on you at its discretion
in connection with accepting your case or providing services from time to time. If your case is
accepted, the retainer agreement will set forth the terms of representation and
payment of fees and costs.
You have completed the intake form for your consultation appointment. You may
either press the Submit Intake Form button below and send the information to
Martin Law Firm or press the Next Page button to continue to the Payment by
Credit Card form.

Payment for the consultation is due at the time of the consultation and credit card
payment will not be processed until that time. Payment may also be made at the
time of the in-office consultation by credit card, cash or check.

Information submitted is by secure server and kept confidential.
   
CREDIT CARD PAYMENT INFORMATION

Information submitted is by secure server and kept confidential.
Please provide information regarding the credit card that will be used to pay for the consultation.

The consultation fee is $100 for time spent up to one hour; if the consultation exceeds one hour,
the additional time will be charged at the attorney's normal hourly rate.

By providing the information below, you are authorizing the credit card to be charged for the $100
consultation fee and any additional fees for time spent beyond the initial hour.

If there is a limit to be placed on charges for this card, please note this in the Comments area below.

If the credit card holder is someone other than the client, please either email your authorization to
firm@brettwmartin.com or give written authorization to the client to bring to the consultation.

Photo identification is required from the client at the time of the initial office consultation.
Name of Credit Card Holder
Please enter the name of the credit card holder
Card Type
Please select the type of credit card
Card Number
Please insert the 16-digit credit card number
Expiration Date
Please enter date card expires
Verification Number or V-Code
Please enter V-Code number
Cardholder House Number & Street
Please enter street number or P.O. Box number
City, State and ZIP Code
Please enter ZIP Code
Questions, Comments & Messages