Intake Form - RBX Law

Please complete the following intake form. We will contact you once you submit the form.

Name (required)

Date of Birth (required)

Address (required)

Telephone (optional)

Email (required)

I agree to receive text messagesI do not want to receive text messages
By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message and agreeing to our Privacy Policy which is located under the "About Our Firm" section. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information. RBX Law, PC does not share personal data or consent with third parties for marketing or promotion.

Driver License (required)

U.S. Citizen? (required)

Military Veteran (required)

Employer (required)

Charges (required)

Date of Arrest (required)

Arresting Agency (required)

Prior Convictions (required)

Case Number (required)

Court Date (required)

What other information do you want us to know?