Potential Client Intake FormPlease complete the form below, we will get back to you shortly."*" indicates required fieldsYour Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Email* Your Phone*Brief Description of Legal Need You Are Calling About*The questions below are optional but will result in a quicker, more informed response from our Client Services Team.1. Does your legal need relate to your company? Yes NoProvide your company name and address.2. Will there be anyone else making decisions with you? Yes NoProvide their full legal name, email address, and phone number. 3. Who referred you? What is their name so we can thank them.4. Were you referred to a specific FJGG attorney? If so, who?5. Please provide the legal names or company names of all opposing parties involved (The party with opposing interests to the other party in a lawsuit. The party on the other side of the transaction.):6. What expenses related to your legal need have been incurred so far or will be incurred?Type text from imageDISCLAIMERDo not send any confidential or sensitive information in this email. Information in this email is not subject to the attorney-client privilege. We are not required to keep this email confidential. We may represent someone against you and can use this email against you. We do not become your lawyers by receiving this email. You cannot become a client of Frascona, Joiner, Goodman and Greenstein, P.C. until you speak with one of our lawyers and reach an express agreement for legal representation.You must agree to the disclaimer to have your message sent.* I have read and agree with the above DISCLAIMER
