Client Intake Form | Example Legal Service

How did client hear about our office?

Referral Source:

👤

2. Client Information

Full Legal Name

Preferred Name

Date of Birth

Address

Home Phone

Cell Phone

Email Address

Occupation

Employer

📞

3. Alternative Contact Information

Alternate Contact #1

Name

Relationship

Phone

Alternate Contact #2

Name

Relationship

Phone

Alternate Contact #3

Name

Relationship

Phone

Additional Means of Contact

Work Phone

Work Email

Preferred Social Contact (if authorized)

Permission to contact through alternate contacts if client is unreachable? Yes No

⚖️

4. Conflict Check Information

Adverse Party Information

Name

Representative (if known)

Address (if known)

Additional Parties

Witness

Police Officer

Badge Number

Conflict Search

Conflict Search Conducted By

Date

Conflict Identified?

No Yes

📋

5. Matter Information

Area of Law

Matter Type

Offence Date

Charge

Court Location

Next Court Date

🎯

6. Client Objectives

The client seeks:

Withdrawal of Charge
Reduction of Charge
Reduction of Fine
Avoidance of Demerit Points
Trial Representation

Other

📝

7. Preliminary Facts

Summary of Client's Account

📅

8. Important Dates

Date	Description

♿

12. Accessibility & Accommodation

Do you require any accommodation to participate in meetings, hearings, or communications?

Yes No

If yes, please describe:

✅

13. Client Acknowledgements

Client acknowledges:

Information provided is accurate to the best of their knowledge.
No solicitor-client relationship exists until the retainer is accepted and confirmed.
The firm may contact alternate contacts if the client becomes unreachable.
The client is responsible for advising the firm of any changes to contact information.

✍️

14. Signatures

Client Signature

[ Click to sign / type name ]

Print Name

Date

Intake Staff Signature

[ Staff: print name below ]

Print Name & Title

Date

Personal information collected on this form is collected in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA) and will be used for the purpose of opening and administering your file. Questions about this collection may be directed to the Privacy Officer at our office.

Your intake form is step one of a fully automated client pipeline