Intake Form

If you do not know the answer to these questions please either indicate you don't know, or leave the fields blank where you can

All fields marked with * are required.

Client First Name *

Client Middle Name

Client Last Name *

Client Name Suffix (e.g. Jr.)

Client Other Name (if any)

Client Date of Birth *

Client SID

Client Race

Client Gender

Client Address Line 1

Client Address Line 2

Client City

Client State

Client ZIP Code

Client Phone Number *

Does the client have any other open cases? *

Is the client currently on probation or parole? *

Does the client identify as queer or trans?

Is the client in a facility that matches their gender?

Is the client pregnant?

Does the client need transportation assistance for court dates?

Does the client need any housing assistance?

Does the client need any employment assistance?

Does the client have any health concerns?

Does the client have a personal contact we should notify?

Personal Contact First Name

Personal Contact Last Name

Personal Contact Relationship

Personal Contact Phone Number

Personal Contact Email Address

Your First Name *

Your Last Name *

Your Phone Number *

Your Email Address *

Your Relationship To The Client *

Your Preferred Contact Method *

How much $ do we need to take to the bail commissioner?

Where is client being held?

Date of Arrest

Time of Arrest

Details of Arrest

Was the arrest in connection with a protest?

Was this arrest for a violation of probation?

Case Number *

What is the total bail the Judge set? (could be bigger than what is due)

What percentage of bail is required?

Attorney First Name

Attorney Last Name

Attorney Phone Number

Attorney Email Address

Attorney Type

Other Information

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