Panel Attorney:	Referral Number:
Referral Subject Area:
Client:	Phone Number:
Address:	Work Number:

RETURN COMPLETED FORM IMMEDIATELY (WHETHER CLIENT APPEARED FOR APPOINTMENT OR NOT) TO THE LAWYER REFERRAL SERVICE, DELAWARE STATE BAR ASSOCIATION, 1201 ORANGE STREET, 11^TH FLOOR, WILMINGTON, DE 19801.

Client contact/Fee collection:

o	1. Client appeared for appointment.
	$35 was collected and is enclosed.
	(If client fails to pay before interview begins NO consultation services are to be rendered.)
	$35 was collected by Delaware State Bar Association.
o	2. Client was contacted but did not desire appointment.
o	3. Client was contacted but did not appear for appointment.
o	4. Client could not be contacted.
o	5. Client out of state – phone consultation (fee collected and enclosed.)

Disposition after client contact

o	1. Further services determined to be unnecessary.
o	2. Arrangements were made for additional legal services.
o	3. Further services by me may be called for later.

Comments:

To be read and signed by the client:

The client hereby acknowledges that neither the Delaware State Bar Association, any officer or member thereof, nor the Lawyer Referral Service Committee makes any representation concerning the attorney to whom the client has be referred except that such attorney is a member of the Delaware State Bar Association admitted to practice law in the State of Delaware. The client hereby waives any claim against the Delaware State Bar Association or the Lawyer Referral Service based on this attorney referral.

Attorney’s Signature

Client’s Signature