Consultation Request | Earth Esquire

Prospective Client Request for Consultation Questionnaire

Thank you for your interest in consulting with Mehaffey PA (the Firm). Please complete this questionnaire as fully and accurately as possible. The information you provide helps the Firm determine whether it can schedule an initial consultation and identify the general nature of your request to be prepared for discussion during the consultation if it moves forward.

Please do not send any confidential documents, highly sensitive information (such as Social Security numbers, bank-account numbers, passwords, or medical-record numbers), or time-sensitive materials unless the Firm specifically requests them. The unilateral submission of documents prior to a conflict check may not be protected under the attorney client confidentiality rules of the Florida Bar.

Please note that the submission of this questionnaire does not create an attorney-client relationship.

Prospective Client Information

First name

Last name

Preferred Name (if different)

Business / Entity Name (if applicable)

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Phone

Preferred Method of Contact

Phone Call

Text Message

E-Mail

May the Firm leave a voicemail or send a text message at the number above?

Yes

Language or accessibility accommodations requested (if any):

Referral and Conflict-Check Information

Referral source or referring person/organization (if any):

To assist with the Firm’s conflict check, please identify all persons, businesses, organizations, insurers, or government entities involved in or materially connected to your legal issue, including any adverse or potentially adverse parties.

1. Name of person or entity

1. Contact information (if known)

1. Relationship to the issue

2. Name of person or entity

2. Contact information (if known)

2. Relationship to the issue

3. Name of person or entity

3. Contact information (if known)

3. Relationship to the issue

Additional parties involved? (not listed above)

Yes

Are you seeking assistance individually, for a business, or for another person or entity?

Individually

Business Entity

Another Person

Other

If a business or entity is involved, provide its legal name, state of formation, and your role:

Prior or Current Representation

Are you currently represented by an attorney regarding this issue or a related issue?

Yes

If yes, provide the attorney’s name, law firm, telephone number, email address, and the scope/status of the representation:

Have you previously consulted or retained another attorney regarding this issue?

Yes

If yes, identify the attorney or firm and explain briefly

Litigation, Claims, Demands, and Deadlines

Are you currently involved in litigation, arbitration, mediation, an administrative proceeding, a governmental investigation, or another formal legal proceeding?

Yes

Have you received or sent a demand letter, notice of claim, summons, complaint, subpoena, cease-and-desist letter, administrative notice, or similar legal correspondence?

Yes

If you answered yes to either question, provide all available details, including the court or forum, case number, parties, dates of service or receipt, upcoming hearing dates, response deadlines, and any action already taken:

Are there any deadlines, hearings, statutes of limitation, closing dates, or other time-sensitive events that may affect this issue?

Yes

If yes or unknown, explain and provide the relevant date(s):

Have any documents been filed with a court or agency?

Yes

If yes, identify the documents and attach copies only if requested by the Firm:

File upload

Description of the Requested Legal Assistance

Please describe the issue for which you seek legal assistance. Include the relevant events, principal persons or entities, approximate dates, and the outcome you hope to achieve.

What steps, if any, have you already taken to address this issue?

What documents or evidence do you have that may relate to this issue?

Is there any information that you believe is especially urgent or important for the Firm to know before a consultation?

Consultation Availability

The Firm offers an initial free 15-minute consultation, subject to availability and completion of a conflict check. Please provide at least two dates and times when you are available.

1. Preferred Date / Time

Month

Day

Year

Time

HoursMinutes

2. Preferred Date / Time

Month

Day

Year

Time

HoursMinutes

3. Preferred Date / Time

Month

Day

Year

Time

HoursMinutes

Acknowledgments and Disclaimers

By submitting this questionnaire, I acknowledge and agree that:

1.-No guarantee of representation. A completed questionnaire, a conflict check, a response from the Firm, or an initial consultation does not guarantee that the Firm will represent me. The Firm may decline a request for a consultation or representation for any lawful reason, including an actual or potential conflict of interest.

2.- Conflict check. The Firm will conduct an initial conflict check against its current and past clients and matters. I authorize the Firm to use the information in this questionnaire for that limited purpose. If the conflict check identifies an actual or potential conflict, the Firm may decline the request for a consultation and may be unable to explain the basis for that decision.

3.- No attorney-client relationship; prospective client confidentiality. I understand that no attorney-client relationship is created unless and until the Firm and I enter into a written representation agreement signed by the Firm and me. I will not treat the Firm as my attorney unless and until that occurs. I understand that I am submitting this questionnaire with the intent to be a prospective client of the Firm, pending the conflict check. If the Firm moves forward with scheduling a consultation, then I will be considered a prospective client of the Firm and any information, materials, or documents disclosed in response to a request from the Firm, or disclosures during the consultation will be held confidential.

4.- Preliminary nature of consultation. Any legal guidance or advice provided during the initial consultation will be based solely on the Firm’s initial review of this questionnaire and a brief review of applicable law. The Firm will assume that the facts I provide are true and complete. The Firm does not guarantee that preliminary guidance will identify every factual issue, legal issue, deadline, claim, defense, remedy, or risk.

5.- Further services and hourly fee. Any further consultation, document review, legal guidance, or advice beyond the initial consultation requires either (a) a written representation agreement or (b) a second consultation at the Firm’s hourly fee of $350.00 per hour, unless the Firm and I agree otherwise in writing before the additional consultation or services are provided.

6.- Accuracy and updates. I certify that the information provided is true and accurate to the best of my knowledge. I will promptly notify the Firm if material information changes or if I learn of a deadline or urgent development.

7.- No reliance for urgent deadlines. I understand that submitting this questionnaire does not stop, extend, preserve, or satisfy any deadline. I remain responsible for protecting my rights and complying with all applicable deadlines unless and until the Firm expressly agrees in writing to represent me.

I have read and understand this questionnaire, including the acknowledgments and disclaimers above.

Printed Name:

Today's Date

Electronic Consent

By checking this box, I choose to submit my electronic signature and understand that the submission of this form is the legal equivalent of my manual signature.

Signature

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