Intake Form

Important Note: This intake form seeks the information of potential clients only. Please do not submit this form if you, yourself, have not been charged with an offense.

Thank you for your interest in my services. To speed up your phone or office consultation, please complete this intake form prior to your appointment.

If you do not currently have an appointment, please use the "other comments" section at the bottom of the form to request an appointment. I prefer in-office consultations, however, if you are not in the area and would prefer a phone consultation, please let me know that. Please be patient and allow up to one business day for a reply to your appointment request.

*(denotes required field)

Name: *

E-Mail Address: *

Type of Case:

Who recommended me to you? How did you get my name?

Phone: *

How old are you? *

Do you have a commercial driver's license?

Driver's License class and state (e.g., IL Class D):

Mailing Address: *

What offense(s) have you been charged with?

What county is your case in (e.g., Coles County, Cumberland County, etc.)?

If a petty traffic case, brief summary of facts:

What are your goals for your case(s)?

List prior tickets/arrests/offenses (county, offense, result, and date):

Other Comments:

CAPTCHA Code: *

Phone: 217-348-6767

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Intake Form