Mass LOMAP Individual Consultation Intake

Upon completion of this form, you will receive an email from MassLOMAP with instructions to schedule your consultation.

We only require name, email address, and a note on your concerns to schedule a consultation. However, we encourage you to complete the additional information for our records (and for returning clients, any updates).

First Name

Last Name

Email Address

Please select all topics you would like to discuss

Please list any other concerns

Pronouns

If other pronouns, please provide

Additional Information

Home Phone

Work Phone

Mobile Phone

Best method to reach you is:

Office Street Address

Office Address City

Office Address State

Office Address Zip

County

Gender Identification

Birthdate

Required format: MM/DD/YYYY

Ethnicity

Bar Admission Status

Law School

Graduation Year

Employment Status

How did you hear about Mass LOMAP? Please check all that apply.

Bar Association	Board of Bar Examiners
Board of Bar Overseers	Client
Colleague, Friend, or Family	CPCS
Employer	Exhibitor Table at Event
Internet Search	Judge/Judiciary
Law School	LCL Clinical Staff
Mass Lawyers Weekly	Other:
Practicing with Professionalism	Presentation by LCL \| Mass LOMAP Staff
Print Advertisement	Read Article by LCL \| Mass LOMAP Staff
Recovery Meeting	Social Media
SJC Standing Cmte on Lawyer Well-Being	Treatment Provider
Web Advertisement

If other, please specify:

Name of individual referral source, if desired:

If mandated, by whom?

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By submitting this form, you agree to our Terms of Service.

Questions or concerns? Email jamice@masslomap.org or call 857-383-3250.

Contact Information