LAW OFFICE OF MICHELLE PERETZ PLLC

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5512 MERRICK ROAD, MASSAPEQUA, NEW YORK 11758

TEL.: (516) 268-0072 EMAIL: MICHELLE@MICHELLELAWOFFICE.COM

Thank you for contacting our law office. Please read the privacy policy below, and then fill out this form as soon as possible. This form must be completed in its entirety prior to any consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 128-bit SSL encryption.

Your personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you.

Contact information: Proposed Client

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Gender

Male

Female

Other

Preferred Contact Method

Marital Status

Separated

Divorced

Widowed

Single

Married

Domestic Partner

Engaged

Contact information: Spouse or Domestic Partner

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Address *

Type

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Do you have children?

Yes

Driver's License Number

Proposed Client - You will be required to upload the front and back of a valid driver's license.

Driver's License Number

Spouse / Domestic Partner - You will be required to upload the front and back of Spouse's or Domestic Partner's valid driver's license.

Please upload a copy of your Driver's License entered in the previous question. If you do not have a Driver's License, please upload other valid photo ID.

Add attachment

Please upload a copy of your Spouse/Domestic Partner's Driver's License entered in the previous question. If they do not have a Driver's License, please upload other valid photo ID.

Add attachment

Are you currently employed?

Yes

What are type of legal services are you interested in? Select all that apply:

Surrogate Court - Probate or AdministrationEstate Planning - Last Will & TestamentAdvance Directives - Power of Attorney, Healthcare Proxy, Living Will, Standby Guardian for Minor ChildrenElder Law Planning - Medicaid / Long Term CareEstate Tax Mitigation - Reduce Exposure for Estate TaxesCollege Age Documents (18+)Supplemental or Special Needs Planning

How were you referred to our law firm?

Friend or family member

Another attorney

Online search or lawyer directory website

Bar Association

Other

If our law firm ends up representing you in this matter, will you be the person who pays the legal fees?

Yes

ACKNOWLEDGEMENT AND ACCEPTANCE

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

THANK YOU

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.