Office Use Only – J. D. Hiznay

Conflicts Check

By submitting this form you agree that you have read this disclaimer. Filling out this form and sending it to J.D. Hiznay, PLLC will not create an attorney client relationship, although your information will be kept confidential. This form is protected by HTTP Secure, a communication protocol using Transport Layer Security. Use of this form is at your own risk.

Your Name*
Your Legal First Name Your Legal Last Name
Your Street Address*
Street Address Address Line 2 City State ZIP Code
Your Email Address*
Please enter a personal email address.
Enter Email Confirm Email
Your Private Phone Number*
Please enter a private daytime phone number if possible.
Student (Potential Client) Legal Name*
If you are the student, please enter your own name. If the student is your child, please enter your child's name.
Legal First Name Legal Last Name
Describe the student's living situation.*
Please select from the drop down menu.
Does your child have another parent or guardian?*
Please select from the drop down menu.
Legal Name of Your Child's Other Parent or Guardian*
Legal First Name Legal Last Name
Are you married to your child's other parent or guardian?*
Please select from the drop down menu.
Street Address of Your Child's Other Parent or Guardian
Please enter the street address of your child's other parent or guardian. If not known, leave blank.

Street Address Address Line 2 City State ZIP Code
Email Address of Your Child's Other Parent or Guardian
Please enter a personal email address. If not known, leave blank.
Enter Email Confirm Email
Private Phone Number of Your Child's Other Parent or Guardian
Please enter a daytime phone number, if known.
Are you married to a person who is not your child's legal guardian?
If yes, please enter the name of your spouse.
Legal First Name of Your Spouse Legal Last Name of Your Spouse
Is your child's other legal parent or guardian married to another person?
If yes, please enter the name of their spouse. If not known, leave blank.
Legal First Name of Their Spouse Legal Last Name of Their Spouse
Student's Street Address Other Than Your Own*
Please fill this in if the student lives at any address other than yours part of the time or all the time.

Street Address Address Line 2 City State ZIP Code
Name of Student's School*
Enter the school where the student is currently or expects to be enrolled. If not applicable, enter "none."
School District*
Please select from the drop down menu. If not applicable, select "none."
Student's Assigned Grade*
Please select from the drop down menu. If the student has been promoted to the next grade, select it. If not applicable, enter "none."
Do you have a meeting or hearing scheduled within the next week?*
- Yes
- No
How do you know about J.D. Hiznay, PLLC?*
Please check all that apply.
- Referral from doctor, therapist, lawyer or educator
- Referral from a non-profit organization
- Email list
- Website
- Word of Mouth
Is there anyone we can thank for the referral? If not, please enter "no."*