Personal Injury Client Intake Form

What is your first name?

What is your last name?

What is your current address?

What city do you reside in?

What is your date of birth?

What is your home phone number?

What is your work phone number?

When is the best time of day/night to contact you?

What is your social security number?

What is your current relationship status?

If you have a spouse, what is their name and contact information?

What was the name of the last educational institution you attended?

What is the address of the last educational institution you attended?

What is the highest level of education you have achieved?

How often are you checked into the hospital?

If you frequent the hospital often, what is the typical reason for your visit?

Do you take prescriptions?

If yes, for what medical condition(s)?

Is this medical condition or conditions ongoing?

Who is your current employer?

What is your professional occupation?

What is your regular salary?

When was the last date you worked before your accident?

What date did you return to work?

Did your accident cause you to be placed on house rest?

If yes, for how long?

Do you plan to return to work?

If yes, when?

If no, why not?

What is your relationship like with your current employer?

Have you ever had problems with your employer before?

If yes, how and when?

What specifically caused your injury?

Who or what do you believe is responsible for your accident?

Were there any witnesses present at the time of your accident?

If yes, how many?

What is your relationship to him/her/them?

What is the address of each witness?

What is the contact information of each witness?

How do you think your accident could have been prevented?

What was the total amount of medical expenses incurred by your accident?

Will these expenses cause you to lose regular income?

Have you spoken to an attorney yet?

Has your life changed as a result of your accident?

If yes, how has it changed?

Have you ever been involved in any accidents before?

If yes, when and how?