New Client Intake Form
Thank you for your interest in Curtis, Curtis & Brelinski, P.C. This form is used to collect information about
potential new clients and is used for internal purposes only. The information you provide is confidential and
will be treated accordingly.
Name: ____________________________________________________________________________________
Home Address: _____________________________________________________________________________
City/Township: _______________________ County: ______________ State: ________ Zip: ______________
Home: _________________Cell: ______________________
Email Address: ___________________________________________________________________
Driver’s License No.: ______________________ Soc. Security No.: _______________________
Date of Birth: ____________________________
Employer: _______________________________ Your Occupation: _______________________________
Marital Status: Married Single Widowed Divorced
Spouse Name: ________________________________________________
Employer: _______________________________ Spouse Occupation: _____________________________
How did you learn about our firm?
Personal Referral Internet Other
Name of referring person:
_________________________________________________________________________________
How would you prefer to have correspondence with this office?
U.S. Mail E-Mail
How would you prefer to receive your invoices?
U.S. Mail E-Mail
Brief Summary of Legal Issue:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
NOTICE ABOUT ATTORNEY-CLIENT RELATIONSHIP
The purpose of this initial consultation is to determine if Curtis, Curtis & Brelinski, P.C. can assist you
with your legal needs, to inform you about the services our firm provides, and to discuss the potential agreement
for the provision of legal services and formation of an attorney-client relationship. This initial consultation does
not create an attorney-client relationship and does not mean Curtis, Curtis & Brelinski, P.C. will act as your
attorneys. After the initial consultation, if your case/matter is accepted by Curtis, Curtis & Brelinski, P.C. and
you desire to retain Curtis, Curtis & Brelinski, P.C. as your attorneys, we will provide you with a written fee
agreement which will set forth the terms of the agreement for legal services. Upon receipt of the signed fee
agreement and the required retainer, we will begin to act as your attorneys.
Your legal rights may be affected by laws that place time restrictions on certain legal claims or may be
otherwise affected if prompt action is not taken. If Curtis, Curtis & Brelinski, P.C. does not accept your
case/matter or you decide not to retain our services you should seek alternate legal counsel immediately to
ensure that your legal rights are not affected. CURTIS, CURTIS & BRELINSKI, P.C. WILL NOT TAKE
ANY ACTION ON YOUR BEHALF PRIOR TO RECEIPT AND ACCEPTANCE BY OUR LAW FIRM OF
A SIGNED FEE AGREEMENT AND REQUIRED RETAINER FEE.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THE FOREGOING NOTICE AND
UNDERSTAND THAT CURTIS, CURTIS & BRELINSKI, P.C. WILL NOT ACT AS MY
ATTORNEYS OR TAKE ANY ACTION ON MY BEHALF UNLESS AND UNTIL A WRITTEN FEE
AGREEMENT SIGNED BY BOTH PARTIES AND THE REQUIRED RETAINER FEE ARE
RECEIVED AND ACCEPTED BY OUR LAW FIRM.
Date: ________________
Signature:
____________________________________________________
____________________________________________________
