General Intake Form Bailey Galyen

General intake form bailey galyen

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DATE: ___________ BAILEY & GALYEN
Name _______________________________________________________________________________ DOB: _____________Sex: M ____F____
Last Name First Middle Maiden
Place of birth___________________________________________________________________________________________________________
City County State Country
Social Security Number: _____________________________ Drivers License Number: _______________________________ State_________
Address: __________________________________________________________________________________Apt. #______________________
City: __________________________________________ County: _______________________ State: __________ Zip: ____________________
Home Phone: (________) ____________________________________ Work Phone: (_______) _______________________________________
E-Mail Address: _____________________________________________________Cell Phone: (______) _________________________________
 I authorize emails concerning my case.  I authorize emails of general interest from Bailey & Galyen

□ I authorize a follow up call regarding my consultation. If yes, please list a contact number. (______)_______________________
Place of Employment: __________________________________________________Job Title: ________________________________________
Address of Employment: _______________________________City_____________ St______Zip_________ Annual Salary________________
Spouse’s Name: ________________________________(Maiden name)_________________________ DOB: ____________________________
Address(if different from yours): _________________________________________City: _____________________State: ______ZIP: ________
Employer: __________________________________________________ Work Phone: _______________________________________________
PERSON FINANCIALLY RESPONSIBLE: Name_____________________________________________________ DOB: _____________________
Address:____________________________________City:__________________State:______Zip:________Phone: _______________________
Social Security Number: _____________________________________ Drivers License Number: ________________________State_________
EMERGENCY CONTACT INFORMATION: Name_____________________________________________________________________________
Address: ________________________________________________City: _________________________State: _____________Zip: __________
Home Phone: (_______) ___________________________________ Work Phone: (________) ________________________________________
What legal action(s) were you involved in previously, if any? __________________________________________________________________
Have you or family member been involved in any type of accident in the last two years? Yes_______ No_______
Have you or a family member ever suffered any serious injuries after taking a prescription or non-prescription drug? Yes_____ No _____
Do you currently have a will? Yes ________ No ________
Have you been denied Social Security benefits? Yes __________ No _________
Have you been denied Veterans benefits? Yes ________ No _________
Do you have need of legal assistance for any immigration matter? Yes_________ No _________
Purpose of visit today: __________________________________________________________________________________________________
HOW WERE YOU REFERRED TO US? (Circle one) Office Sign I’m a Previous Client Bar Association B&G Letter TV Ad Radio
Billboard Website WebChat In Mesquite Phonebook: name of book _________________________________________
Friend: Name of Friend________________________________ Other: ___________________________________________________________________
Bailey & Galyen Employee: Name _________________________________ An Attorney: Name of attorney ______________________________________
INTERVIEWING ATTY __________________ CONFLICT CHECK PNC __________CP_________BXL INI____________
CONFLICT CHECK OP ___________CP_________BXL INI____________
FEE QUOTED__________________ COST QUOTED _________________ PNC CONTACT ENTERED IN CP___________________ INI____________
OP CONTACT ENTERED IN CP____________________ INI____________
DOWN PAYMENT QUOTED___________________ REVISED 2-17-11
Social Security information will only be used in the event you hire the firm to
represent you in your legal matter, and then only when necessary in limited use
during the course of your case

• Social Security numbers are collected by the law firm from the client and all
clients provide such information to the firm in writing

• Social Security numbers are most often used to positively identify parties

Some uses may include initial service, in court orders, in orders to withhold
wages for child support, in required reports filed with the State of Texas, or
to obtain retirement information used to divide retirement benefits. Most
courts require Social Security numbers of all parties

• All information received from a client is confidential. Numbers are not
released from the firm unless authorized by the client or required in the
course of representation as previously stated herein

• The employees of Bailey & Galyen have access to this personal information

• Every step is taken to protect your privacy. This information is kept secure
within the offices of the firm in file folders and file drawers until such time
that the file information is retired and the file removed to storage in a locked,
off-site storage facility. Files will eventually be shredded after the time
designated by the State Bar requirement for maintaining the records has
expired. Social Security numbers are also kept in firm software programs
that are protected by password in our system which is further protected by
extensive firewalls

I acknowledge that I have read the above privacy information provided by Bailey &
Galyen regarding use of my Social Security number

______________________________________ __________________
Signature Date

All information received from a client is confidential. Numbers are not released from the firm unless authorized by the client or required in the course of representation as …

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Frequently Asked Questions

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We offer an exceptional level of attention, respect and skill to each of our clients. Bailey & Galyen may be a large law firm, but we have a commitment to carefully tailored legal representation. *There is a $150 charge for Civil Law consultations. **Excluding personal injury, workers’ compensation, and social security disability cases.

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At Bailey & Galyen, our family law attorneys bring years of experience to our clients throughout Texas. We built our family law and divorce practice and reputation on a commitment to personal service and attention, combined with a dedication to apply the highest standards of legal excellence to every case we handle.

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1901 Airport Fwy. Call for an appointment at an office near you. Bailey & Galyen is one of the most recognized consumer law firms in Texas who has provided legal services for over 30 years. We offer an exceptional level of attention, respect and skill to each of our clients.

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