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).

Please select your position in the Massachusetts legal community. (LCL | Mass LOMAP services are exclusively for Massachusetts.)

First Name

Last Name

Email Address

Pronouns

If other pronouns, please provide

Consultation Information

Please check if you've met with one of our LCL | Mass LOMAP advisors or clinicians before.

Yes

Please select all topics you would like to discuss

Please describe your concerns and list any other concerns you may have, providing as much detail as you would like -- please note that this intake form is secure and confidential, and providing this information can help us make the best match..

If you would like to meet with a specific advisor, please select here. Find their bios here, on our full staff listing.

Contact & Other 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?

Your consultation includes a subscription to our emails. Check below if you'd like to opt out.

Opt Out

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