To request a consultation and discuss your legal issues with an
attorney, please complete the form below. If your
situation requires immediate attention, you should call our
office directly to confirm whether we please complete the form below.
There is a $100.00 charge for an initial one-hour
consultation session.
* Required Fields.
Title*:
First
Name*:
MI
Last
Name*:
E-mail
Address*:
(ex. johndoe@anywhere.com)
Home
Phone*:
(ex.
505-555-5005)
Work
Phone:
(ex.
505-555-5005)
Mobile
Phone:
(ex.
505-555-5005)
Street
Address:
City:
State
/ Zip:
/
(ex. NY /
10005-1009)
Injured Person
Information:
Date
of Birth:
Whom
are you inquiring on behalf of?
If you are NOT
inquiring on your own behalf,
what is your relationship?
Is the person deceased?
Yes
No
If deceased, the cause of
death
as stated on the death certificate:
Date of Death:
Was there an
autopsy performed?
Yes
No
n/a
Case Information:
Date of Accident or Injury:
Occupation :
Name and Address of Employer:
Describe Related Injury:
Does Injury Prevent Working?
Yes No
If yes, when did you stop
working:
Approximate Money Lost Due to
Injury:
Other Information:\
Yes No - I agree
that this matter may be referred to an attorney in my area
who may contact me.
Yes No - I
agree that by submitting this question, I will not be charged for the
initial response. I understand that I am forming only a
semi-confidential relationship.
Yes
- I agree that the above does not constitute a request for legal
advice and that I am not forming an attorney client
relationship by submitting this question. I understand that I
may only retain an attorney by entering into a fee agreement, and
that I am not hereby entering into a fee agreement. I agree
that the information that I will receive in response to the
above question is general information and I will not be
charged for the response to this e-mail question. I further
understand that the law for each state may vary, and therefore, I
will not rely upon this information as legal advice. Since
this matter may require advice regarding my home state, I
agree that local counsel may be contacted for referral of
this matter.
By Clicking the
appropriate box below, I agree to:
