Intake Form

🔒 Secure Form — This form is transmitted over an encrypted (HTTPS) connection. All information is sent directly to The Chetson Firm and is protected by attorney-client privilege. Website Personal Information First Name * Middle Name Last Name * Street Address Town State Zip Telephone Cell Phone Other Contact Person Other Contact Number Other Contact's Relation E-Mail Address Social Security Number NC Driver's License # Date of Birth Age Marital Status Sex Level of Education Race Custody Location (if applicable) Inmate Number (if applicable) Family Information Spouse/Partner Name Spouse Address (if different) Town, State, Zip Spouse SSN Spouse DOB / Age Spouse Phone Spouse Cell Phone Is the client a minor? Father / Caregiver Name Phone Address Town, State, Zip Cell Phone Employer Occupation Work Address Work Phone Mother / Caregiver Name Phone Address Town, State, Zip Cell Phone Employer Occupation Work Address Work Phone Siblings (oldest to youngest) Name Date of Birth Additional Notes Children (oldest to youngest) Name Date of Birth Employment Information Name of Employer Occupation Employer Address Town, State, Zip Work Phone Work Fax Start Date End Date (if applicable) Previous Employer Last Employer Phone Start Date End Date Spouse's Employer Employer Occupation Address, Town, State, Zip Work Phone Is client a student? Name of School Grade School Address Town, State, Zip School Phone Teacher/Counselor/Administrator Military History Has client been in the military? Branch of Service Years of Service Discharge Status Criminal History Ever convicted of a crime? Past Convictions (list) Other pending charges? Pending Charges Does client have another attorney? Attorney's Name(s) Attorney's Contact Is client on probation? Probation Officer Probation Contact Court & Case Information Name of Court Case No. District Attorney / Prosecutor District Attorney Name of Prosecutor Prosecutor Phone Prosecutor Fax Prosecutor E-Mail Assistant/Paralegal Assistant's Phone Charge Details G.S. Sec. Class Description Facts of Case Arresting Agency Officers Involved Date of Offense Date of Arrest Present Status PTR Supervisor PTR Phone Location if in Custody Bail / Bond Bail Bond (if set) Amount of Bail Name of Bondsman Witness Names / Contact Co-Defendant(s) Co-Defendant Attorneys Co-Defendant Attorneys' Contact Narrative Please describe the situation in your own words By submitting this form, you acknowledge that this information will be transmitted securely to The Chetson Firm, PLLC. Submission of this form does not create an attorney-client relationship. All information provided is confidential.