Potential Client Form

Thank you for your interest in our firm. Upon receiving this information, we will review your potential claim and respond as soon as possible. Typically, we respond by scheduling an initial interview an attorney in our firm, either in person or by phone. Completing this form does not guarantee legal advice or the formation of a lawyer/client relationship. Please DO NOT SEND CONFIDENTIAL documents or information. All contact information provided will be handled only in the manner set forth in our privacy policy. If you have any questions, please call 313-967-0700.

Personal Information
Name:
 (Required)
Address:
 (Required)
Floor/Apt/Suite:
City:
 (Required)
State:
 (Required)
Zip:
 (Required)
Telephone:
 (Required)
Fax:
E-mail:
 (Required)
Best time to contact:
Date of birth:
Your Education:

Family Information
Spouse's Name:
Spouse's Employer:
Spouse's Position:
Children's Names/Ages:
Other Information:
Question/Concern Information
The following are screening questions to avoid any conflicts of interest and to make sure that this office might be able to assist you
Are you a potential plaintiff or defendant?
Nature of your complaint/question:
Employer (or former Employer):
 (Required)
Current or last date employed:
Years with employer:
Employer's Address:
Employer's Telephone:
Supervisor:
Job Title:
Salary/Per Hour Earnings:

Please give a description of the claim or issue. (Required)
Please be brief, but thorough. If necessary we will ask for more details when we respond to your concern:

What type of resolution do you expect or want concerning this issue.
(For example, "I want my job back", monetary compensation, etc.)

Have you already spoken with an attorney?:
 (Required)
If yes, whom:
Do you have a lawsuit of any kind pending:
 (Required)
If yes, where:
Have you ever been party in a lawsuit of any kind:
 (Required)
If yes, where:
Any additional comments:

(Your form will not be processed until you click submit)

 
Copyright © 2011
The Kienbaum Law Group, P.C.
The International Center Building, 400 Monroe, Suite 470, Detroit, Michigan 48226
313-967-0700 / Fax: 313-967-0244
This website is designed for general information only. The information presented at this site should not be construed to be formal legal advice nor the formation of a lawyer/client relationship.
Persons accessing this site are encouraged to seek independent counsel for advice regarding their individual legal issues.