If yes, provide the full name of the lawyer and the dates he/she consulted or represented you, and include reasons for the termination of representation.
Describe existing issues implied in "Other"
Identify any prescription and over the counter medications which you or the opposing party are
currently taking (including dosages)
If yes, provide date, County/State, offense(s) charged, offense(s) plead, offense(s) convicted, and
punishment
If yes, identify the provider(s), state the dates of care, and describe the issue(s) addressed
If yes, identify the provider(s), state the dates of care, and describe the issue(s) addressed