Client Intake

PLEASE COMPLETE THIS FORM

You should provide your contact information, specifically your email and phone number directly to the court so they can arrange for your first appearance.
If you can afford an attorney, you should hire one as soon as possible.
If you cannot afford an attorney, please fill out this form.

Name*

First NameLast Name

Home address where you receive mail (with apartment number)*

Street Address

Street Address Line 2

CityState

Zip Code

Cell Phone Number*

Please enter a valid phone number.

Alternate Phone Number*

Please enter a valid phone number.

Email

Required to receive a confirmation upon completing this form.

Date of Birth*

Date

Age*

Gender*

Race*

Marital Status*

Do you need an interpreter?*

YesNo

What Language*

Court Name*

Next Court Date and Time:*

Date

Hour MinutesAM/PM Option

Please answer yes or no to each item below:

Are you currently employed?*

YesNo

Do you have or have you in the past had a drug issue?*

YesNo

Do you have or have you in the past had an alcohol issue?*

YesNo

Do you have or have you in the past had a mental health issue?*

YesNo

Are you under 21 years old?*

YesNo

Document Upload:

If you have a copy of your charges, appearance ticket or any other paperwork, please upload it here.

NOTE: If you have trouble uploading documents, please email them to pdcharges@co.rockland.ny.us

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Allowed File Types: pdf, doc, docx, jpg, jpeg, png, gif

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