Consultation Form



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For immediate assistance seven days a week, call (714) 961-1966.

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Free Consultation for Elder Abuse/Neglect

Use this simple form to provide us with information that will help us prepare for your free consultation. The information you are providing via this form shall be treated confidentially and is protected under the Attorney-Client privilege. Once received, we will phone you back at our earliest convenience.

Please note that this form is for elder abuse/neglect cases only. Use these links for other types of cases:
NOTE: * indicates a required field.
Personal Information
First Last
Date of Birth (mm/dd/yyyy)
City, state, zip
(At least one phone number is required.
Use the format 555-555-5555.)
Work ext.
Case Information
Briefly explain what happened to the elder/dependent adult.*
Have you reported the incident to the local police, Ombudsman's office, or Department of Public Health/Social Services? Yes    No
Please provide the name of the agency contacted.
Describe the elder's/dependent adult's injuries.*
Where is the elder/dependent adult currently living?
Information about the nursing home or person(s) (name and address) you believe committed the abuse
Other Details
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Other (please indicate):

Perez & Perez respects your privacy and does not sell or share your confidential information with any other parties. Read more about our privacy practices in our Privacy Policy.
The information provided at this web site by Perez & Perez, including all emails and newsletters, is not intended to be legal advice, and legal representation is subject to additional terms and conditions of a signed contract. To read more about this, please see our Legal Disclaimers.



1440 N. Harbor Blvd., Ste. 900, Fullerton, CA 92835, Phone: (714) 961-1966, Fax: (714) 961-1972

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