Civil Rights Questionnnaire

Please complete the following form in advance of your appointment. Thank you.

Name*

Date of Incident*

Address*


Home Phone*

Cell Phone*

Email*

Date of Birth*

Do you believe that you have been denied your civil rights by the Government?

Local?

State?

Federal?

Describe Incident

Please describe how you have been hurt or damaged by this incident, and any treatment you are receiving, if applicable