Confidential Client Intake

Tell Us About Your Situation

This form is protected and confidential. The information you provide helps us evaluate your matter before your consultation.

Transmitted over encrypted HTTPSStored securely — accessible only to firm staffProtected by attorney-client privilege upon engagement

1Personal Information

First name *

Last name *

Email address *

Phone number *

Date of birth

Used to verify your identity with consumer reporting agencies.

Last 4 digits of SSN

Do not enter your full Social Security Number.

Current street address

City

State

ZIP

Previous addresses (past 5 years, if different)

Consumer reporting agencies may use prior addresses to locate your file.

2Consumer Report Details

Type of matter

Consumer Reporting Agency (CRA)

Which agency provided the report at issue?

Approximate date report was pulled

Reason the report was pulled

3Nature of the Inaccuracy or Violation

What specific information is incorrect or at issue?

Additional context about the error

Include any relevant dates, court case numbers, or other identifying details.

4Creditor or Debt Collector Details

Creditor or collector name

Account number (last 4 digits OK)

Approximate amount claimed

Status of the account

How has the collector contacted you? (FDCPA matters)

Include approximate dates, frequency, and any threats or misrepresentations made.

5Dispute History

Have you already filed a formal written dispute with the CRA or background screening company?

YesNo

6Damages and Harm

Describe any concrete harm you have experienced. This information helps us assess the strength of your claim and the remedies available to you.

Adverse action taken against you

Include the employer, landlord, or lender name and approximate date if known.

Financial losses

Emotional distress

7Supporting Documents

Upload any documents that support your matter — court records showing dismissal or expungement, a copy of the consumer report, dispute letters, CRA responses, identity theft reports, or adverse action notices. You can also take a photo with your phone camera.

Document security: Files are transmitted over an encrypted HTTPS connection and stored in a secure, access-controlled location. They are accessible only to authorized firm staff and are not shared with any third party. Do not upload documents containing your full Social Security Number, full financial account numbers, or passwords. Redact sensitive identifiers before uploading where possible.

Accepted: PDF, JPG, PNG, HEIC, WEBP — up to 10 MB per file. On mobile, you can use your camera to photograph documents.

8Additional Information

Anything else you would like us to know?

How did you hear about us?

Important notice before submittingSubmitting this form does not create an attorney-client relationship. No such relationship is formed until a written engagement agreement is signed by both you and the firm. The information you provide is confidential and will be used solely to evaluate your potential matter. Do not include your full Social Security Number or complete financial account numbers in any text field. If you have time-sensitive legal deadlines, please call us directly at (770) 766-7911 rather than relying on this form.