Client Intake Form

Complete this form so we can review your situation before your consultation. All information is confidential and protected by attorney-client privilege.

Secure & Confidential — Attorney-Client Privilege Applies

Contact Information

Your basic contact details

Full Legal Name*

Phone Number*

Email Address*

Street Address

City

State

Zip Code

Date of Birth

Last 4 of SSN

Employment & Income

Helps us assess your options and any exemptions that may apply

Employment Status

Employer Name

Gross Monthly Income

Other Monthly Income

The Debt in Question

Tell us about the specific debt you need help with

Current Creditor / Collector Name*

Original Creditor (if different)

Account Number (last 4 digits)

Current Balance Claimed

Type of Debt

Date of Last Payment

Amount of Last Payment

Lawsuit Status

Have you been sued or served with court papers?

Have you been served with a lawsuit or summons?

Other Debts & Overall Financial Picture

Helps us evaluate whether bankruptcy or other options may be appropriate

List any other significant debts (creditor, balance, type)

Approximate Total Debt (all creditors)

Approximate Monthly Expenses

Number of Dependents

Assets

Tennessee exemptions may protect certain assets from creditors

Bank / Checking Accounts (approx. balance)

Real Estate (address & approx. value)

Vehicles (year, make, approx. value)

Other Assets

Prior Bankruptcy

Have you ever filed for bankruptcy?

Goals & Additional Information

What outcome are you hoping for?

Additional notes or questions

How did you hear about us?

Upload Documents

Optional — attach summons, collection letters, account statements, or any other relevant documents

Click to upload or drag and drop

PDF, Word, JPG, PNG — up to 20 MB each, max 10 files

Helpful documents: summons or complaint, collection letters, account statements, any correspondence from the creditor or their attorney.

Ready to Submit?

Your information will be sent securely to Shaffer Law Office. We will follow up within one business day.