The following information is for myself:   Yes   No

If “No” please fill in the following information:
My Relationship

My First Name

My Last Name

My Email

My Telephone No.

Potential New Client Information

Client First Name

Client Middle Initial/Name

Client Last Name

Client Maiden Name (if applicable)

Client Home Street Address and Apt No.

Client Home City

Client Home State

Client Home Zip

Client Email

Best Number to be reached at

OK to leave VM at this number?  Yes   No

Secondary Number to be reached at

OK to leave VM at this number?  Yes   No

Spouse/Opposing Party Information

First Name

Middle Initial/Name

Last Name

Maiden Name (if applicable)

Case Information

County

Number of Children (and ages if any)

Date of Separation

Date of Divorce

Any Court filings

Spouse’s Attorney (if known)

--- Internet Former Client Attorney Friend Other Referred by

Attorney preference

--- Heather A. Cooper David L. Ginsberg Daniel L. Gray Nathan J. Olson Stephanie J. Smith Robert M. Worster III Specific

Choices
--- Partner Associate

--- Man Woman

--- Most Expensive Least Expensive

Any other information

Please provide us with a very brief overview, in 200 words or less, describing in general the subject matter of your request. You can provide more detailed information below, but for now please confine yourself to providing us with a brief statement of the general facts of your case.

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