Basic Intake Form - Law Office of Glenn A. Deig

What is the date of your appointment?

What time is your appointment?

:

What is your full legal name?*

Preferred Name

Do you have a preferred name or nickname?

If you are attending a consultation regarding someone else’s planning, what is the full legal name of that person?

For instance, if you are attending an asset protection consultation with a parent to discuss asset protection for that parent, then you would enter your parent’s full legal name in this space.

If you are attending a consultation regarding someone else’s planning, what is your relationship to that person?

For instance, if you are attending a consultation with a parent, then you would enter “son” or “daughter” in this space.

Date of Birth

What is your date of birth?

Address

What is your address?

Street Address Address Line 2 City State ZIP Code

Home Phone Number (if applicable)

What is your home phone number?

Cell Phone Number (if applicable)

What is your cell phone number?

Email Address (if applicable)

What is your email address?

If you are married, what is the name of your spouse?

Is this client a previous client or has this client had a previous consultation with Glenn A. Deig?

Yes
No
Not sure

How did you hear about Glenn A. Deig, Attorney at Law?

Anything else?

If there is something that you’d like for us to know prior to your appointment, feel free to mention that in the space provided below.