Evaluation Form

1401 North Elm Avenue, Suite 230
Santa Ana, California 92705
(714) 555-1212 — (714) 555-5652 FAX

Submit this form for a FREE case evaluation based on the information you provide. — All information is NOT required. Fill in as much as you can. — All information will be kept strictly confidential. — If there are privacy issues with us contacting you (Ex. "only call at night"), be sure to fill in Contact Notes.
*Contact Information:* (You can supply specific contact instructions in"Notes")
Contact Name
Home Phone
Work Phone
FAX
E-mail
Contact Notes:
Client Information:
Client Name
US Citizen
Date of Birth
In Custody
Jail Name
Booking Number
Bail Amount
Prior Arrests
*Case Information:*
Charges/Accusations
Arrested
Arrest Date
Case Number
Court
Next Court Date
Case Facts: (Use as much space as you need)
Statement of the Case
Search and/or Confession issues
Witness Issues
Other Defense Issues