Civil Rights Intake Form - Blue Lotus Law

Basic Information

Todays Date

Your Full Name

Date of Birth

Social Security

Race

Gender

Male

Female

Other

Marital Status

single

married

divorced

separated

Drivers License Number or another form of ID

State

Contact Information

Current Address

Current Address cont.

Phone Number

Email Address

REFERRED TO OUR FIRM BY

Spouse/Significant Other Information

Spouse/Significant Other Name

Spouse Age

Spouse Race

Number of Years Together

Spouse Address if different

Spouse Address if different cont.

Spouse Telephone if different

Spouse Email Address

Marriages/Divorces

Spouses Name | Date/Place of Marriage | How Marriage Terminated | Date/Place Filed

Children

Child Name | Gender/Age | Living With | Name of Other Parent

Educational History

Schools Name | Dates Attended From/To | City/State | Degree Obtained

Most Recent Employment History

Business Name | Position(s) Held | Dates Employed From/To | Reason for Leaving

Information Regarding Your Claim

Name of the individual agency or entity that you feel treated you wrongly

What is the basis of your claim?

What is the Basis of Your Claim?

False Arrest

Excessive Force

Negligence

Medical Negligence

Selective Enforcement

Malicious Prosecution

Deliberate Indifference, Resulting in Serious Injury

Other

Civil Rights Violations Based on:

Race If so List your race

National Origin If so list your nationality

Disability/Handicap (If so list your Disability/Handicap)

Disability/Handicap (If so list your Disability/Handicap) cont.

What was the date of the LAST Wrongful Action which you are basing you claim

Where did you Wrongful Action take place

Have you solicited the Representation of any other Attorney(s) in reference to this claim? (If so, whom and why did you not proceed with them?)

Whom and why did you not proceed with them 1

Whom and why did you not proceed with them 2

Whom and why did you not proceed with them 3

Whom and why did you not proceed with them 4

Whom and why did you not proceed with them 5

Whom and why did you not proceed with them 6

Whom and why did you not proceed with them 7

IF CURRENTLY INCARCERATED, COMPLETE THE FOLLOWING

Place of Incarceration

Address

Address cont.

SPN or DOC

Length of Sentence

Date which current Incarceration began

Schedule release date

Offenses which you are being currently incarcerated 1

Offenses which you are being currently incarcerated 2

Offenses which you are being currently incarcerated 3

Do you anticipate being transferred from your current location to another facility? If so list that location if known

During this period of incarceration, have you experience disciplinary actions? (If so, how many times & for what reason):

If so how many times for what reason 1

If so how many times for what reason 2

If so how many times for what reason 3

CRIMINAL HISTORY SUMMARY

Offense | County/State | Year Occurred | SentenceRow

OTHER GENERAL INFORMATION

Answer the following questions to the best of your ability. If your answer to ANY of these questions is YES, please explain on the prompt below.

Have you ever hired or consulted with a lawyer concerning this problem?

Yes

No

Have you otherwise sued anyone or been sued by anyone (except divorces)?

Yes

No

Have you been diagnosed with a mental illness or disability?

Yes

No

Have you ever been hospitalized or confined for a mental illness or disability?

Yes

No

Have you ever been adjudicated incompetent?

Yes

No

Do you suffer from serious physical illness or disability?

Yes

No

Are you currently taking any prescription medications?

Yes

No

Have you previously (during the period of your claim) taken prescription medication?

Yes

No

Are you addicted to drugs or alcohol?

Yes

No

Do you regularly use drugs or alcohol?

Yes

No

Have you ever been treated for drug or alcohol abuse?

Yes

No

Have you ever been rendered totally or partially disabled?

Yes

No

Have you ever applied for disability compensation benefits?

Yes

No

Have you ever been CONVICTED of a felony or misdemeanor?

Yes

No

Have you ever served in the military?

Yes

No

Have you ever filed bankruptcy?

Yes

No

Have you ever filed a complaint or grievance with regard to any lawyer who provided legal services to you?

Yes

No

Do you have any plan or intention to file bankruptcy?

Yes

No

Have you ever hired a lawyer to represent you and terminated the lawyer’s services before representation was complete?

Yes

No

During the period in which you claim you were wronged, were there anyother stressful events in your life, such as births, deaths, divorces, marriages,significant problems with your children or family, criminal acts against you,etc.?

Yes

No

Have you received treatment by any medical or mental health professional as a result of the action or occurrence which you are now complaining?

Yes

No

Have you given any verbal, written or recorded statements to any person or entity regarding the issues which are the basis of this current complaint?

Yes

No

Are you currently an absconder or fugitive from any entity?

Yes

No

IN THE SPACE PROVIDED BELOW, PLEASE DESCRIBE IN YOUR OWN WORDS (AND IN DETAIL) THE EVENTS THAT HAVE LED YOU TO BELIEVE THAT YOU WERE TREATED WRONGFULLY BY THE ENTITY OR ENTITIES YOU HAVE PREVIOUSLY IDENTIFIED.

IF YOUR ANSWER TO ANY OF THE QUESTIONS ON THE PREVIOUS PAGE IS “YES,” PLEASE EXPLAIN IN THE AREA BELOW.

WITNESS LIST

Use this page to identify and describe any person(s) who have DIRECT knowledge regarding your claim(s). Include people which you deem to be either friendly to your claim, hostile to you or your claim or neutral. REMEMBER, THIS INFORMATION MAY PROVE TO BE VERY IMPORTANT TO YOUR CASE.

Witness 1 Name/Contact Info

Radio Buttons

Friendly

Hostile

Neutral

Witness 2 Name/Contact Info

Radio Buttons

Friendly

Hostile

Neutral

Witness 3 Name/Contact Info

Radio Buttons

Friendly

Hostile

Neutral

Witness 4 Name/Contact Info

Radio Buttons

Friendly

Hostile

Neutral

Witness 5 Name/Contact Info

Radio Buttons

Friendly

Hostile

Neutral

Follow

In your opinion, WHY do you think you were treated wrongfully?

What action or comment, (if anything), did you, do which you think “might” have provoked the wrongful action taken against you?

Have you personally witnessed others being subjected to the same wrongful action which you claim happened to you? If so, please describe.

What damages do you believe you have suffered as a result of the wrongful action you are claiming in this intake? Please be specific regarding any wages you feel you may have lost, indebtedness you have incurred and/or physical, mental, or emotional injuries you believe you have suffered.

What do you REALISTICALLY hope to achieve, receive, or gain from bringing a civil action against the party or parties who you feel treated you wrongfully? Please be specific.

SIGNATURE

DATE