New Client Intake Form Nuddleman Law Firm, P.C. 1Your Information2Adverse Party3Adverse Party4Adverse Party5Description and Acknowledgment Your Name(Required) First Last Your Email(Required) Phone(Required)Your Address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are you:(Required) The Employee The Employer Acting on Behalf of an Elderly or Disabled Person Your Position/Title:SalaryAnnual WagesStart Date of Employment Month Day Year When did you begin working for the employer?End of Employment Month Day Year When did you stop working for employer (if applicable)? Name of Employer First Others who have harmed you:Type of Issues Termination Discrimination Harassment Wage & Hour/Unpaid Wages Disability Accommodations/Medical Leave Defamation/Libel/Slander Other UntitledType of Discrimination Sex/Gender (including Gender Identity or Sexual Orientation) Age Disability Pregnancy Race Religion Citizenship Military/Veteran Status Other Type of Discrimination Legal Name of Employer(Required)Type of EntitySole ProprietorshipCorporationLLCPartnershipName of Principle Owners First Separate names with a comma Adverse Party or PartiesSeparate names with commas Type of Issues Termination Discrimination Harassment Wage & Hour/Unpaid Wages Disability Accommodations/Medical Leave Defamation/Libel/Slander Other Untitled Name of Care Recipient(Required)Relationship to Care Recipiente.g., Conservator, Trustee, Daughter, etc. City where services are provided First In which city are the services are provided? Adverse Party or PartiesSeparate names with commas Brief Description of Issues(Required)What do you hope to gain from the consultation?Referred by:Please let us know who referred you.ACKNOWLEDGEMENT REGARDING FEES AND COSTS FOR THE CONSULTATION The attorney will charge a reduced fee of $350.00 per hour for the initial consultation. Fees are due and payable by check, cash or credit card immediately following the consultation. Work beyond the initial consultation will be billed at attorney's regular billing rate plus costs. By writing my name below, I acknowledge that I understand the fee arrangement and agree to pay for the services rendered. *(Required) I have read and agree to the consultation fee. Draw your Initials in the box below.(Required)CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
