Intake Form

"*" indicates required fields

In order to be of service to you, this office requires certain information. Rather than expend time collecting this information during your consultation with us, we have prepared this Intake Information form and ask that you complete same to the best of your ability.

Instructions for Completing Form:

Prospective or current client must complete all fields
Completion of this form does not create an attorney/client relationship. Information disclosed in this form is both privileged and confidential under the New York Rules of Professional Conduct.

Contact Information

Name*

Mailing Address*

Mailing Transfer

Physical Address Same as Mailing Address

Physical Address*

Cell Phone Number*

Email*

Your Preferred Contact Method

Emergency Contact Name

Emergency Contact Telephone Number*

Biographical Information

Date of Birth*

English-Speaker?

If no, preferred language?

Marital Status

Children

Number of Children

U.S. Citizen

Immigration Status

Known Alias(es)

Employer's Name

Time Employed?

Job Title

Monthly Pay

Specialized Training?

Highest Education

Driver's License State & No.

Driver's License Status

Do you have a pistol permit?

Are there firearms in your house?

Military service?

Branch of Service

Please list any prior criminal or DWI/DWAI convictions and the approximate month and year of conviction

Click the plus sign to add additional convictions, if necessary.

Conviction

Date

Are you currently on probation or parole?

Please provide the following for any vehicle you own, operate or lease:

Only fill out if DWI Case. Click the plus sign to add additional vehicles, if necessary.

VIN

License Plate

Make

Model

Year

Color

Insurer

Source of Referral

How were you referred to us?

Provide name and phone number if friend, relative, or attorney

Present Charge(s) Information

Offense(s) charged:

Date(s) of alleged offense(s):

Court Date

Court Time

Court of Jurisdiction:

Where case is pending (if known)

County of Jurisdiction (if known):

Where case is pending (if known)

Who is your current attorney for this case?

Your Version of Events

Questions You Would Like Answered by Your Attorney

Click the plus sign to add additional questions, if necessary.

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Comments

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WE ARE HERE TO FIGHT FOR YOU

Your case matters. We commit our full resources and attention to a successful result.

Intake Form

Contact Information

Biographical Information

Source of Referral

Present Charge(s) Information

Get Started

Disclaimer

Call 845-566-5345 Today.

Larkin Ingrassia, PLLC

Attorneys At Law

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Newburgh Office

Middletown Office

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