My Virtual Law Firm





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Street Address	*
City, St Zip	*
Date of Birth	MM/DD/YYYY
Social Security Number
Place of Birth
Email Address	*
Home Phone	*(NOTE: Due to the confidential nature of any communications from us, we ask that you list only the telephone numbers where you can be reached. Do not list telephone numbers at which you do not wish to be contacted.)
Work Phone
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Best Time to Contact
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Brief Description of Services Requested
Other Parties
Lawyers for Other Parties
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Do you have an attorney?	Yes No
Acknowledgement	I acknowledge that submitting this form via the internet does not establish an attorney/client relationship. I further acknowledge that acceptance of this matter by The Virtual Law Firm for the purposes of Case Evaluation, Alternative Dispute Resolution, Document Preparation, Negotiation Support, Lawyer Correspondence, and/or Litigation Support does not establish a full scope attorney/client relationship but creates only a limited scope representation. I further acknowledge that the attorneys of The Virtual Law Firm are individually licensed and are permitted to practice law in the state or states in which they are authorized to practice law. I desire to engage The Virtual Law Firm to assist me in resolving a legal dispute or otherwise addressing a legal issue. I understand that The Virtual Law Firm does not undertake full scope legal representation of any client but acts in a limited capacity to advise, instruct, and assist persons who are representing themselves or attorneys representing their clients. If I conclude at any point that I should retain an attorney for full scope legal representation, I understand that I am free to do so and that The Virtual Law Firm may refer an attorney to me upon request if I am an established client of The Virtual Law Firm. I ACCEPT THESE LEGAL TERMS AND CONDITIONS. Yes No

Whenever possible, established clients will be notified of their username and password by email within approximately two (2) business days. Your username and password will be forwarded to the email address or addresses listed on your account. All communications with established clients are through our secured communications network. In order to protect the confidentiality of our established clients, it may be necessary to contact you during business hours (9:00 AM until 5:00 PM EST) to confirm your identity. However, we will be unable to verify your username or password by telephone. If you forget your username or password, we will notify you via email of your username and password. If your email address changes, please inform us immediately.

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