Personal Injury Intake

Thank you so much for contacting our law office! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security numbers are most often used to positively identify parties. Most courts require Social Security numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

CLIENT'S INFORMATION

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

ACCIDENT INFORMATION

OTHER PARTY

If KNOWN / APPLICABLE

WITNESSES

STATEMENTS MADE

INJURIES

SYMPTOMS

INJURY HISTORY

Have you had any accidents or injuries before this accident?

LOSS OF EARNINGS

If you anticipate loss of earnings due to accident related injuries, please complete the following:

ADDITIONAL INFORMATION

DOCUMENT REQUEST

Please upload or email any documents that would be helpful for the case such as:

Medical Records

Medical Bills

Insurance Correspondence

Accident Reports

Police Report

DOCUMENT REQUEST

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.

CLIENT'S INFORMATION

Contact information

Pronouns Used

Social Security Number

Driver's License Number

Are you married?

Do you have any military service?

ACCIDENT INFORMATION

Is this an auto accident?

Date of Incident

Time of Incident

City of Incident

County of Incident

Road/Intersection

Were the police called to the scene?

Was an accident or incident report filed?

Your understanding of how the incident occurred.

Photo / Diagram Upload

OTHER PARTY

Name of Other Party

Other Party's Address

Other Party's Phone Number

Other Party's Job / Occupation

Other Party's Age

Other Party's Insurance Company

Other Party's Insurance Adjuster

Other Party's Insurance Coverage

Give your observations about the party as a person.

WITNESSES

Witness #1

Witness #2

Witness #3

Witness #4

Additional Witnesses or Information

STATEMENTS MADE

Have you told any police officer, investigator, insurance adjuster or any other person about the accident?

INJURIES

Please describe any and all aches, complaints, discomforts and disabilities, as a result of accident related injuries, in detail.

Did you go to the hospital?

Did you go by ambulance?

Did they take x-rays?

Have you seen a doctor since the date of the accident, other than at the emergency room?

SYMPTOMS

Check symptoms you have noticed since the accident

INJURY HISTORY

Past Injury #1

Past Injury #2

Past Injury #3

Past Injury #4

Additional Past Injury Information

LOSS OF EARNINGS

Employer

Your Position or Title

How are you paid?

How many hours do you normally work per week?

Were you working at the time of the accident?

ADDITIONAL INFORMATION

Any additional Information you think would be helpful?

DOCUMENT REQUEST

Would you like to attach the above documents now?

DOCUMENT REQUEST