Legal Hotline for Texans

Are you filling this out for someone other than yourself?*

Yes No

Such as a grandmother, brother, friend, etc.

Name of the person filling out this form*

First Name

Last Name

Phone number for the person filling out this form*

Do you have power of attorney?*

Yes No

We are required to speak directly with the potential client. Please have the person you are applying for call us directly at (800) 622-2520.

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

County*

Phone*

Email*

Marital Status*

Single Married Divorced Widow or Widower Unmarried Partner

Name of spouse*

Do you live in the same household as your spouse?*

Yes No

Citizenship*

Citizen Lawful in the U.S. Undocumented

Are you disabled*

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Are you a veteran?

Yes No

Date of birth*

What is the best time of day to reach you?

Ethnicity*

Asian Black - Not Hispanic Native American Other Ethnic Group Native Hawaiian/ Pacific Islander White - Not Hispanic Hispanic Prefer Not to Answer

Gender*

Male Female Other Transgender

Do you receive Medicare?*

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How many adults are in your household?*

How many children are in your household?*

What is the monthly income for your entire household?*

Do you have assets apart from your home and vehicles?*

Yes No

Please list those assets and their estimated values*

Name of the adverse party

The person or organization you are complaining about.

Briefly describe your legal issue*

Legal Hotline for Texans Intake Form