JASINSKA LAW FIRM PROFESSIONAL CORPORATION

245 Fischer Ave Suite D2 Costa Mesa, CA 92626

Phone: 866-248-0535 | Local: 949-662-3056

Fax: 949-818-5113

Thank you for contacting our law office!
Please review the privacy notice below and complete the attached form before your consultation.

Privacy Notice:
Your information is confidential and protected by 256-bit SSL encryption. Personal details, including your Social Security Number, will only be used if you retain our firm, and only as necessary (e.g., court filings, legal documents).

Consultations are private. We may decline representation or be unable to assist you if a conflict of interest exists.

Next Steps:

Email all supporting evidence for your claim — limit total attachments to 100 pages.
Include key details such as communication history, names, dates, and a brief summary of the issue.
Attach relevant documents like medical records, police/investigation reports, photos, videos, legal filings, or witness statements.
This information is required for a conflict check.

If you have questions, the best way to reach us is by email. We look forward to helping you.

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

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Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

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Phone numbers

Phone number

Type

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Preferred Contact Method

Gender

Male

Female

Social Security Number

Driver's License Number

Marital Status

Single

Married

Separated

Divorced

Widowed

Are you currently employed?

Yes

No

How were you referred to our law firm?

Friend or family member

Another attorney

Online search or lawyer directory website

Billboard, bus stop, phone book, newspaper, or other physical advertisement

Orange County Bar Association

Rocketlawyer

LACBA SMART LAW LOS ANGELES COUNTY BAR ASSOCIATION

U.S. LEGAL SERVICES

If you are suing what type of matter is it

Personal Injury Matter

Medical Malpractice Matter

Nursing Home Abuse

Wrongful Death

Emergency Orders of Protection

INFORMATION ABOUT YOUR CIVIL DISPUTE

IMPORTANT DATES AND WITNESSES

SUMMARY OF REASONS YOU ARE SEEKING LEGAL ADVICE AND REPRESENTATION

TYPE OF DAMAGES

DAMAGES TO THE PROPERTY OR PERSONAL INJURY

LOSS OF INCOME

ANY OPEN CASES?

ANY HEARING DATES?

IS THERE ANY AGREEMENT BETWEEN THE PARTIES IF YES UPLOAD THE COPY

DOES THE CLIENT HAVE A CONDITION LIMITING THEIR ABILITY TO WORK?

DO YOU CURRENTLY HAVE AN ATTORNEY REPRESENTING YOU

DO YOU NEED EMERGENCY ORDERS OF PROTECTION IF YES GIVE MORE DETAILS

ARE YOU READY TO HIRE AN ATTORNEY

PLEASE PROVIDE INFORMATION ON THE OPPOSING SIDE NAME ADDRESS EMAIL PHONE NUMBER

If our law firm ends up representing you in this matter, will you be the person who pays the legal fees?

Yes

No

ATTACH YOUR SCANNED DOCUMENTS HERE

Yes

PICTURES

Please indicate the source of funds or otherwise confirm that you have the ability to pay your legal fees.

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POLICE REPORTS

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RECEIPTS

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REPORTS

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MEDICAL REPORTS

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MEDICAL RECORDS

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OTHER

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INSURANCE POLICY

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No

ACKNOWLEDGEMENT AND ACCEPTANCE

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

THANK YOU

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.