Office Use Only 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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.Student is a minor living with parent(s)/guardian(s) in same home.Student is an adult living with parent(s)/guardian(s)Lives with both parents/guardians, in separate homes.Does not live with either parent.Student is an adult living independently.Other / Not ApplicableDoes your child have another parent or guardian?*Please select from the drop down menu.YesNoNot Applicable / This inquiry is not about my child.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.Yes, we are married and live together.Yes, we are married but we live apart.No, we are divorced.No, we were never married.No, I am widowed.Street Address of Your Child's Other Parent or GuardianPlease enter the street address of your child's other parent or guardian. If not known, leave blank. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address of Your Child's Other Parent or GuardianPlease enter a personal email address. If not known, leave blank. Enter Email Confirm Email Private Phone Number of Your Child's Other Parent or GuardianPlease 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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."Arlington CountyCity of AlexandriaCity of Falls ChurchFairfax CountyPrivate SchoolPost-Secondary (e.g. George Mason University)Virginia (other school districts)Outside VirginiaNoneStudent'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."Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade +College/Post-SecondaryNoneDo you have a meeting or hearing scheduled within the next week?*YesNoHow 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."*