New Client Intake Form

Use this form to add a new BRM client

Client Name

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

Applic. Date

Primary Advocate (email)

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

Primary Issues

(Provide brief description of client issue)

Intake Notes

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

Client Primary Language?

Which language would client prefer to be contacted in?

Client Phone Number

(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

Client E-mail

Client Mailing Address

Next Meeting Scheduled

Please note the DATE of your next meeting with the client

mm/dd/yyyy

Next Meeting TIME

Please note the TIME of your next meeting with the client

Next Court Date

Please note next client court date

mm/dd/yyyy

Referral Source

Send me a copy of my responses

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