TLSC General Intake Form

Are you seeking legal advice for yourself or someone else?	Myself
Name *:
Address *:
City *:	State:       Zip:
County *:
Phone *:
Alternate Phone:
Email:
What is the best time of day to reach you by telephone?
Date of Birth:	(xx/xx/xxxx)
Do you receive Medicare?	Yes     No
How many people live in your home?
Average monthly income of your entire household?	Choose One $500 or less $500-800 $800-1,200 $1,200-1,500 $1,500-2,000 $2,000 or more
Briefly describe your legal problem: limit 800 characters	Characters Left