LRIS Client Referral Intake Form

Client Referral

Contact with our Lawyer Referral and Information Service puts you in touch with a pre-screened lawyer with whom you may schedule a half hour appointment for a $40 fee—instead of the lawyer's normal hourly fee.

The fee may be paid by debit or credit card by filling out the form below.

NOTE: The $40 fee is waived for personal injury, medical malpractice, workers’ compensation, victim compensation, and social security disability. Fees for additional services beyond the consultation are arranged between you and the lawyer.

While completing this form, do NOT click the browser's Refresh tool and do NOT click the back button as this may result in multiple submissions and payments.

Contact Information

* indicates a required field

First Name:*

Middle Name:

Last Name:*

Business:

Address 1:

Address 2:

City:

State:

Zip Code:

E-mail:*

Verify Your Email:*

Home Phone #:

Cell Phone #:

Alternate Phone #:

At least one phone number or e-mail is required.

Representative

Are you filling out this form on behalf of another party?:

Yes

* indicates a required field

First Name:*

Last Name:*

Relationship to Contact:*

Address 1:

Address 2:

City:

State:

Zip Code:

E-mail:

Verify E-mail:

Home Phone #:*

Cell Phone #:

Alternate Phone #:

At least one phone number or a valid email is required if Representative information is provided.

Language

What is your preferred language?:

Legal Issue

Please describe the situations which you feel would necessitate an attorney

Description:

Survey

Would you like to receive surveys regarding the case?:

Yes

Filters

1. To define the type of case, please select the "Primary Panel" then "Sub-Panel" that most closely matches your legal issue.

For example, if you are needing a lawyer to help you with a divorce and your spouse is contesting the divorce, you would select "Domestic" for the primary panel then "Divorce -Contested" for the sub-panel.

2. After submitting, you will be asked to pay a $40 fee, if applicable, and our staff will contact you with the name of an attorney meeting the requirements you have selected.

* indicates a required field

Primary Panel:*

Sub-Panel

* indicates a required field

Languages Spoken: