INSTRUCTIONS:  This form spans 2 pages, required fields are marked with an (R).  At the end of the form you will have the opportunity to review and edit all of the information you provided on the form.  While working on the form, you may go back to previous pages by using the back button at the bottom of the form, however answers on the page you are currently working on when you click the back button will NOT be saved and you will need to re-enter the information, therefore I highly recommend that you complete the entire form, then review and edit your answers.  You may NOT stop part way through the form and come back to it later as your information will NOT be saved for you.  Should you click any links on the form page, the linked page will open in a new window.  Simply close that window to return to the form where you left off.  Clicking a link from the form will not cause your information to be deleted.

You will have the opportunity to schedule an appointment with me for a real-time Internet chat or phone call to discuss your case after you have completed the form.

If you do not have time to fill this form out completely now, please complete the General Response Form and I will contact you about your case.