Initial Consultation Client Intake Form

Note: The purpose of an initial consultation is for the attorney to advise you, the prospective client what if anything, may be done for you, what your rights are, time frames, and what the minimum fee 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:

✔ A. You and the Attorney mutually agree to the terms of representation, and after a separate document a contract of representation (called a Retainer Agreement) is signed by both you are the attorney;

✔ B. The Attorney declines representation; or

✔ C. You decide not to use the services of the Attorney.

Your Full Name *

First

Middle

Last

Opposing Parties Full Name *

First

Middle

Last

Your Mailing Address *

Address Line 1

City

State

Zip Code

Note: Your mailing address should be an address ONLY you have access to, not the opposing party.

Mobile Phone *

Work Phone

E-Mail Address *

Employment Status *

Occupation *

Note: If you are not employed, just type "N/A" or "None"

Employer's Name *

Note: If you are not employed, just type "N/A" or "None" or "Retired"

Employer's Address *

Address Line 1

City

State

Zip Code

Note: If you are not employed, just type: "N/A" or "None" or "00000" or "Retired"

Date of Birth *

Social Security Number *

*256-bit Encrypted Field

Who or what referred you to Kevin Puckett Attorney at Law, LLC? *

Notification of use of E-Mail (Electronic Mail)* *

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Middle

Last

✓ Note: I, Client, do hereby acknowledge that I have been advised by Kevin Puckett Attorney at Law, LLC that copies of all documents received and/or generated by Kevin Puckett Attorney at Law, LLC regarding my case will be forwarded to me via email, and, more specifically, to the email I provided above in this form. The email address I am directing Kevin Puckett Attorney at Law, LLC to forward said documents to is to the email I provided above in this form. I understand it is extremely important for me as a Client to review all of the documents sent to me by Kevin Puckett Attorney at Law, LLC. I further agree to check this email timely and frequently. Finally, I agree that by signing below, I am consenting to receive E-Mail communications.

*By typing my name above I understand, consent and agree to be contacted by E-mail (Electronic Mail).

Notification of use of SMS Text (Text Message)* *

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Middle

Last

✓ Note: I, Client, do hereby authorize Kevin Puckett Attorney at Law, LLC to utilize SMS Text messaging regarding my case. By participating, you consent to receive text messages sent by an automatic telephone dialing system and consent to these terms is not a condition of purchase. The phone number I am directing Kevin Puckett Attorney at Law, LLC to send SMS text messages to is the phone number(s) I provided above in this form. I understand it is extremely important for me, as a Client, to review all SMS text messages sent to me by Kevin Puckett Attorney at Law, LLC. I further agree to check these text messages timely and frequently. Finally, I agree that by signing below, I am consenting to receive SMS communications.

*By typing my name above I understand, consent and agree to be contacted by SMS Text (Text Message).

Driver's License Picture Submission (Front & Back) *

Click or drag files to this area to upload. You can upload up to 2 files.

✓ Note: Please take a picture of the front and back of your driver's license and then attach the photos here.

Legal Files (Previous Judgment or Criminal Tickets)--Field not required.

Click or drag files to this area to upload. You can upload up to 7 files.

✓ Note: Please upload any legal files you wish to have Mr. Puckett review prior to your consultation. For example, this may include a copy of your previous judgment or criminal tickets. It is important to note that you can only upload a maximum of 7 documents that are no larger than 25MB TOTAL.

Today's Date *

PLEASE READ EVERYTHING CAREFULLY & THEN SIGN BELOW TO AGREE *

Clear Signature

✓ Note: You must CLEARLY sign your FULL name above. If your signature is not legible, your will be asked to re-fill/re-submit this entire form. This law office does not undertake to represent you until a separate and written agreement for representation (called a Retainer Agreement) has been executed by you and the attorney.

IMPORTANT NOTICE: Following your initial consultation, if you agree to hire the Attorney, and the Attorney agrees to represent you, you will both sign a Retainer Agreement. The Retainer Agreement will set forth the terms and conditions of representation. If the Attorney is willing to represent you and you decide not to sign a Retainer Agreement, you are strongly urged to to immediately consult with other legal counsel to protect your interest and rights.

If the Attorney does not agree to represent you, it will include not representing you with regard to the matter set forth by you on this information sheet, and any other matters that you may have discussed with the Attorney during your initial consultation. If your legal problem(s) involve a potential legal claim, it is important for you to realize that a legal claim 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 interest and 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 Client Intake Form and does not mean you have hired the Attorney.

This office does not represent you with regard to the matters set forth by which you sought your consultation, the information sheet (initial client intake form) or discussed during your consultation unless and until, both you and the Attorney execute a written Retainer Agreement.

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