New Client Information Form

Note: Fields marked with a * are required
  Client #1
* Salutation:
* First Name
* Last Name
* Nickname
* Address
 
* City
  * State         * Zip   
* Phone: Note: Provide one phone number where you may be reached

Work:        Ext.   
Home:
Cell:
* Best time of day to be contacted:
* Email Address
Attorney for Client #1:  
 Client #2
* Salutation:
* First Name
* Last Name
* Nickname
* Address
 
* City
  * State         * Zip   
* Phone:  


Work:    Ext.   
Home:
Cell:
* Best time of day to be contacted:
* Email Address
Attorney for Client #2:  
Who referred you to DRS?
Were you referred to a particular professional at DRS?
If yes, which professional?
Were you referred for a particular process?  
Is there a Court Order requiring you work with Dispute Resolution Services?     
Has a legal proceeding been started?
If yes, is there a Court hearing scheduled? 
If yes, what is the name and date of the hearing?
Name:
Date:   
Do you have minor children? 
If yes, what are their ages?

Type of Case: (may check more than one option) 






Topics to be Resolved: (may check more than one option)









If Desired, Further Describe Topics to be Discussed
Dispute Resolution Services
Dispute Resolution Services