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Client Intake Form

LOMA'S Sample Form Modify to meet your own situation!
(Reprinted from Florida State Bar Association's LOMA Program, J.R. Phelps, Director)

The purpose of an initial consultation is for the attorney to advise you, the prospective client what if anything, may be done for you, and what the minimum fee therefor will be. The purpose is not to render a definitive legal opinion as it may be impossible to fully assess a matter within the time frame allotted for a consultation or with the (information or documents) that you may be able to provide at the initial consultation.

One of three outcomes is possible following your consultation.

  1. You and the Attorney mutually agree to the terms of representation, or
    (After a separate document called an Agreement for Representation is signed a copy will be provided to you.)
  2. The Attorney declines representation, or
  3. You decide not to use the services of the Attorney.

Note: The following questions will help us to understand the reason for your visit today. Your responses are protected by attorney/client privilege and will be held in strict confidence.

Name  ____________________________________________________________
Last  First  Middle or Maiden
Address ___________________________________________________________
Number  Street  City  State  Zip
Home Phone (_____) _____________

Briefly explain what you may need advice about or assistance with today:



Are there any parties involved? (Examples: a friend, an employer, a neighbor, signor of a contract, etc. This should include parties on either side of your issue)

Party_____________________________ Relationship___________________________

Party_____________________________ Relationship___________________________


On the lines below, list the documents (papers) that you think may help us to understand the issues.

    1. _______________________________________________________________
    2. _______________________________________________________________
    3. _______________________________________________________________

(NOTE: Any documents you supply that are important to your matter will be photocopied, with your permission, and your originals returned to you at the conclusion of the initial interview.)

Ideally, if things turn out precisely the way you want, what would the outcome be?



Knowing that there are no guarantees, what can you accept?




Please classify your urgency in concluding this matter? (check one)

[ ] Critical Personal safety or continuation of business depends on it.
[ ] Very important severe hardship, personal or financial inconvenience if matter is not resolved quickly.
[ ] Important Matter interferes with business or personal financial stability.
[ ] Needs to be done, but no immediate hardship in the interim.
[ ] Just thought I’d see if it was worth pursuing, but I’m not counting on anything.
[ ] Just wanted to know what my rights are? I’ll then let you know after I think about it.

If the matter involves payment of money you feel you are owed, how long can you wait before not getting paid?____________________________________________________
                                 (Days, Weeks, Months, Years)

Are we the first attorneys you have consulted regarding this matter? [ ] Yes [ ] No
If No Why didn’t you hire their services?



Have you ever been represented by an attorney before? [ ] Yes [ ] No
If Yes Please state the circumstances



How will you pay for your attorney’s fees in this matter?
[ ] Check today [ ] Cash today [ ] Contingency Fee [ ] On Account
[ ] Credit Card Credit Card No. ___________________________ Expr. Date________

Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Widowed [ ] Separated

Drivers License # ________________________ Social Security #____ __ ____

Are you known by any other names? [ ] Yes [ ] No
If yes name(s) ____________________________________________________________
(A fictitious name, a nickname, a former name, your maiden name etc.)

Where are you employed?


May we contact you there? [ ] Yes [ ] No Phone No. ( ___) _________________

If your mail is returned as undeliverable or telephone service terminated, please provide the name of someone (friend or relative) you believe will always know how to contact you.

Name_____________________________________ Relationship___________________

Address ___________________________________ Phone No. (____) ______________

__________________________________________ State & Zip ______________ ____

How did you learn of our office [ ] A friend [ ] Yellow Pages [ ] Bar Referral
[ ] Our Web Page http:/ www.yourfirm’ [ ] Former Client [ ] Other


Following your initial interview, if you agree to hire the Attorney, and the Attorney agrees to represent you, you will both sign an Agreement for Representation. The Agreement for Representation will set forth the terms and conditions of representation.

If the Attorney is willing to represent you and you decide not to sign an Agreement of Representation today, you are strongly urged to schedule a second appointment with the Attorney at the earliest possible time or to immediately consult with other legal counsel to protect your rights.

NOTICE: This office does not represent you with regard to the matters set forth by you herein in this information sheet or discussed during your consultation unless and until, both you and the Attorney execute a written Agreement for Representation.

If the Attorney does not agree to represent you, this includes not representing you with regard to the matter set forth by you on this information sheet, nor any other matters you may discuss with the Attorney during your consultation. If your legal problem(s) involve a potential lawsuit, it is important that you realize a lawsuit must be filed within a certain period of time called a Statute of Limitations. Therefore, the Attorney strongly urges you to immediately consult with another attorney to protect your rights. The Attorney’s decision not to represent you should not be taken by you as an expression regarding the merits of your case.

Your signature acknowledges only that you received a copy of this completed information sheet and does not mean you have hired the Attorney.

SIGNATURE ___________________________ DATE ____/____/ ____


This portion to be completed by the Attorney

[ ] Will represent (see New Case Memo and Agreement for Representation attached)

[ ] Will investigate and report (Schedule a follow-up conference for ____ days)

[ ] Representation declined Letter of declination will be sent .

[ ] Party "will think about it" and back with us No action to be taken and party was so informed.

[ ] Client declined Representation at this time.

Interviewed by __________________________ this ____ day of _________ _____












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