Client Intake Form

Contact Information

First Name *

Last Name

Primary Phone *

Email Address *

Preferred Contact Method *

Personal Details

Gender

Date of birth

Place of Birth

Primary Language

Nationality

Social Security Number

Marital Status

Emergency Contact

Emergency Contact Phone

Status

Power of Attorney

Incident Information

Case Type *

Number of Additional Passengers / Cases *

Additional Case [1] Full Name

Additional Case [1] Phone Number

Additional Case [1] Email

Additional Case [1] Relationship to Primary

Additional Case [1] Injury Type

Additional Case [2] Full Name

Additional Case [2] Phone Number

Additional Case [2] Email

Additional Case [2] Relationship to Primary

Additional Case [2] Injury Type

Additional Case [3] Full Name

Additional Case [3] Phone Number

Additional Case [3] Email

Additional Case [3] Relationship to Primary

Additional Case [3] Injury Type

Additional Case [4] Full Name

Additional Case [4] Phone Number

Additional Case [4] Email

Additional Case [4] Relationship to Primary

Additional Case [4] Injury Type

Additional Case [5] Full Name

Additional Case [5] Phone Number

Additional Case [5] Email

Additional Case [5] Relationship to Primary

Additional Case [5] Injury Type

Incident Date *

Incident Location

Brief Description

Injuries Sustained

Injury Type

Injuries

Witnesses

Witness 1
Witness 2
Witness 3

Police Report

Incident Report

Medical Attention

Physician's Name

Hospital Treated At

Current Treatment Status

Medical Bills Estimate

$

Insurance Involved?

Defendant Attorney Name

Estimated Case Value

Liability Assessment

Employment & Education Details

Currently Employed?

Employer Name

Employment Start Date

Employment End Date

Occupation

Position

Salary Mode

Monthly Salary

$

Employment Description

Days Lost from Work Due to Incident

School Information

School/Institute Name

Program/Course of Study

Days Absent from School Due to Incident

Insurance & Vehicle Details

Vehicle Model (if applicable)

Vehicle Year (if applicable)

Policy Number

Vehicle Color (if applicable)

Do you have health insurance?

Insurance Company Name

Do you have collision coverage?

Additional Insurance Details

Prior History & Other Details

Have you had Prior Injury Claims?

Have you had Prior Disability Claims?

Have you had Prior Worker Compensation Claims?

Have you been involved in a Prior Lawsuit?

Name of Previous Attorney (if applicable)

Have you contacted a Competitor Attorney?

Document Uploads

Upload Photo ID

Upload Photo ID

Upload Health Insurance Card(s)

Upload Health Insurance Card(s)

Upload Property Damage Photographs

Upload Property Damage Photographs

Upload Injury Photographs

Upload Injury Photographs

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