General Intake Form Bailey Galyen
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File Name: General-Intake-Form.pdf
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DATE: ___________ BAILEY & GALYEN ATTORNEYS AT LAWName _______________________________________________________________________________ DOB: _____________Sex: M ____F____ Last Name First Middle MaidenPlace of birth___________________________________________________________________________________________________________ City County State CountrySocial 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 RadioBillboard Website WebChat In Mesquite Phonebook: name of book _________________________________________Friend: Name of Friend________________________________ Other: ___________________________________________________________________Bailey & Galyen Employee: Name _________________________________ An Attorney: Name of attorney ______________________________________FOR OFFICE USE ONLY: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 PRIVACY POLICY REGARDING SOCIAL SECURITY NUMBERSSocial Security information will only be used in the event you hire the firm torepresent you in your legal matter, and then only when necessary in limited useduring 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
Why choose bailey galyen?
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.
Why hire baileygalyen?
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.
Where is bailey galyen located in texas?
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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At the Texas probate law firm of Bailey & Galyen, we understand that wills, probate, and trusts are an essential part of life planning. Bailey & Galyen is committed to holding big pharmaceutical companies accountable when they fail to disclose risks of serious injuries and death associated with their products.