New Client Intake Form

Use this form to add a new BRM client

 

Use first name last name format (e.g. Bob Smith)

 
 

(Select advocate to assign new client to from dropdown list)

 

(Provide brief description of client issue)

 

(Provide specific details re. client's case / situation)

 
 

Which language would client prefer to be contacted in?

 

(E.g. 540.123.4567) NOTE: Blue Ridge Mile is requesting permission to contact you via text or email. You will receive a consent form via email to ask your permission. BRM will not contact you until it has your approval to do so.

Phone
 
 
 
 

Please note the DATE of your next meeting with the client

 
mm/dd/yyyy
 

Please note the TIME of your next meeting with the client

 

Please note next client court date

 
mm/dd/yyyy