This form is not to be used if you have received a "Notice of Client's Right to Arbitration", have notice of a lawsuit being filed involving a fee dispute with your lawyer, or have filed a complaint with the State Bar of California.
PLEASE PRINT AND MAIL COMPLETED FORM TO ADDRESS BELOW.  Thank you.

CLIENT REQUEST FOR ASSISTANCE FROM THE 
CLIENT RELATIONS COMMITTEE OF
 THE CONTRA COSTA COUNTY BAR ASSOCIATION

PRINT OR TYPE ALL INFORMATION

1. Your Name_____________________________________________________________
    Address_______________________________________________________________ 
    Telephone_____________________________    Fax____________________________

ATTORNEY WITH WHOM YOU ARE DISSATISFIED

2. Attorney's Name_________________________________________________________
   Firm Name______________________________________________________________
   Address_______________________________________________________________ 
   Telephone_____________________________    Fax____________________________

3. What is/was the legal matter your attorney was employed to handle?
________________________________________________________________________
________________________________________________________________________

4. When did you first contact this attorney?______________________________________

5. Is there a written agreement or contract with the attorney?      YES        NO  (circle one)

6. Have you let your attorney know that your are dissatisfied?     YES       NO  (circle one)
     If so,   ____ in writing,     ____ in person,    ____by telephone

7. When was the last communication?__________________________________________

8. Please give a brief description of your dissatisfaction (attach additional sheets if needed):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

9. Please state what you now want the attorney to do (attach additional sheets if needed):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

I hereby authorize a member of the CCCBA's Client Relations Committee to contact my attorney, convey my concerns, and to receive and review documents from that attorney which may involve disclosure of confidential information.  However, the Committee will maintain the confidentiality of information and documentation, none of which shall be available for subpoena purposes and which shall be destroyed following termination of any assistance from the Client Relations Program.

Date:__________________                                                Signature:________________________________________

PLEASE RETURN THIS COMPLETED FORM WITH ATTACHMENTS TO:
Contra Costa County Bar Association
 Attn: Client Relations Committee
704 Main Street
Martinez, CA  94553

Client Relations Case No: ____________