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 STUDENT, AND KELLER LAW.

We (Keller Law) establish an attorney/client relationship with you ONLY after: 1) we determine the need for attorney services; 2) you have agreed to and signed an engagement agreement with Keller Law; and 3) we have received, from you, retainer trust funds, which will be deposited in an attorney 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 following submitted information provided is truthful to the best of my knowledge, that by completing this form I understand and accept that no attorney client relationship is created between us and Keller Law. I understand that the information I provide 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 student. For example "Sue J. Smith"

Email*

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

Address City State Zip*

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

Are you CURRENTLY retaining an attorney or non-attorney advocate for this matter with the Student?

Yes

Have you ever retained an attorney or non-attorney advocate for this matter with the Student?

Yes

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 an engagement agreement 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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16 Washington Street

Unit 264

Norwalk, CT 06856

info@keller-law.com

Tel: 203-548-0096