Keller Law Intake Page One

Thank you for your interest in Keller Law. Your next step is to complete this online intake form.

COMPLETING THIS ONLINE INTAKE FORM DOES NOT ESTABLISH AN ATTORNEY/CLIENT RELATIONSHIP BETWEEN YOU, YOUR CHILD, AND KELLER LAW. KELLER LAW WILL NOT REPRESENT YOU OR YOUR CHILD IN THIS MATTER UNTIL SUCH A RELATIONSHIP IS ESTABLISHED.

We (Keller Law) establish an attorney/client relationship with you ONLY after: 1) we determine the need for advocacy and/or attorney services; 2) you have agreed to and signed an engagement agreement with Keller Law; and 3) we have received a retainer from you which we will deposit in a separate trust fund account. Even though an attorney/client relationship is not established by completing this form, we will keep all communications with you private and confidential.

If you have any questions, please don't hesitate to contact us. We look forward to working with you!

Acknowledgement*

I agree

I acknowledge that the information provided is truthful to the best of my knowledge, that by completing this form I understand and accept that an attorney client relationship is not present between us and Keller Law, and that this information will remain confidential.

Parent or Guardian Information (Primary Contact)

Full Name of Guardian or Parent*

Please enter the full name of the parent or guardian of the child. For example "Sue J. Smith"

Email*

Primary contact email of Parent or Guardian. We suggest a home not a work email.

Address*

Enter the street address, city, state, and zip code of the Parent or Guardian

Are you the Parent or Guardian*

Parent

Guardian

Marital Status of Parent or Guardian

Single

Married

Divorced or Separated

Other

Cell Phone*

Enter in your area code and number, like 203-444-8787

Your employer

Please indicate either unemployed or if employed the name of the company that the Parent or Guardian works for and their duties.

Internet Access

Computer at home with Internet access

Cell Phone with Internet access

Neither - but I can access the Internet at a library or family or friend

I do not have access to the Internet

Select all that apply

Disclaimer: Attorney advertising materials. The information on this Web site is not, nor is it intended to create an attorney-client relationship between you and Keller Law LLC. Please be advised that no attorney-client relationship is established until a retainer is executed between you and Keller Law LLC. Do not send confidential documents without express prior approval. Outside links provided on this Web site are done so for informational purposes only. Keller Law LLC is not responsible for the contents or accuracy of the materials linked to this website.

KELLER LAW LLC

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48 Calf Pasture Beach Road

Norwalk, CT 06855

info@keller-law.com

Tel: 203-548-0096