Personal Injury Intake Form
Contact Number
Contact Number
Contact Number
Contact Number
"Before we get started, please keep in mind we do NOT give any type of legal advice. We only bring lawsuits."
**Wait for a response. **
"Thank you for your time. Unfortunately, there's not much we can do at this time but if you do change your mind, please do not hesitate to contact us."
IF THE ANSWER IS NO, READ THIS.
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Submit
Name of Person Doing the Intake
Date
-
Month
-
Day
Year
Date
Client Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Preferred Language:
Gender
Male
Female
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Employment Details
Occupation
For how long?
Race/Ethnicity you identify yourself with:
Nationality
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any limitations on contacting you (Email not secure? Cell phone not secure? Etc.)
Driver’s State/License#_
Social Security #
Educational Background
Served in the Armed Forces
Civil Status
If you have children, how many?
Whom the children live with?
What, if there's any medications you take
Have you ever received mental health or substance abuse counseling?
Name of Significant Other
Relationship to you
Living in the same address?
How Long?
Contact Number (Significant Other)
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Personal Injury
State and City of Accident
SOL for auto accident: 2 years, SOL for claim against government: 6 months
What kind of Accident you're involved in
Auto Accident
Slip & Fall
Booking #
What Happened?
Please be as specific as possible. Get the time, street names, and describe.
Is there a police report?
Date & location of accident
Who do you think is at fault for the incident. Why?
Have you received medical treatment within 30 days of this accident?
Please explain all injuries and symptoms since the accident
Start from Head to Toe and explain all injuries and symptoms(headaches, vision problems, et).
If available, please provide the information of the other parties involved
(Others involved with accident) Full name, phone number, insurance information, plate#
What medical treatment did you receive?
For example, ambulance, emergency room, urgent care, doctor, chiropractor
Please provide the contact information for your medical treatment provider
Name of Provider, City, Phone #
Email Address
Main Phone Number to reach you.
When is the best time to call you in the next 24 hours?
How did you hear about us?
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