New Clients

Initial Client Intake Form

Please complete the form below if you would like a consultation with Ms. Carteia Basnight. The information you provide below is confidential and secure. If you prefer to speak by telephone, please call 757-838-0001.

Your Full Legal Name*
First Middle Last
Email Address*
Enter Email Confirm Email
Home Address*
Street Address Address Line 2 City State ZIP Code
Business Address
Street Address Address Line 2 City State ZIP Code
Home Telephone*
Cellular Telephone
Business Telephone
Fax
How do you prefer to be contacted?*
Select all that apply
- Home Telephone
- Cellular Telephone
- Business Telephone
- Email
- No Preference
Date of Birth
For security reasons, your information is masked when entered
Social Security Number
For security reasons, your information is masked when entered
Occupation*
Briefly explain your need for an attorney*
How did you hear about me?
Signature*
Date Signed*
MM slash DD slash YYYY