Language
English (US)
Spanish (Latin America)
Platinum Law Intake Form
“Thank you for calling Platinum Law, my name is [YOUR NAME]. How can I help you to today?"
Today's Date
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Month
-
Day
Year
3 days After
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Month
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Day
Year
"Are you an existing client with our office or is this your first time calling?"
*
First time caller
Existing client
"Since you are an existing client, can you please provide me your previous case number or the date of the previous incident we represented you on?"
*
If they have neither, type "N/A" and gather their full name
"What is your Full Name?"
*
First Name
Middle Name
Last Name
"In case we get disconnected, what is a good call back number for you?"
*
Format: (000) 000-0000.
"What is your date of birth?"
*
/
Month
/
Day
Year
Secondary phone number (If provided by potential client)
Format: (000) 000-0000.
Type of Phone Number
Please Select
Parent
Partner
Work
Other Mobile
"What about a good email address?"
*
Example@Email.com
"We appreciate you reaching out for the first time!"
What language is preferred?
*
Please Select
English
Spanish
Farsi
Other
"Which language IS preferred?"
"How did you hear about our firm? For example, a friend, family, another attorney, online search or something else?"
*
Please Select
Friend
Family Member
Another Law Firm
Online Search
Something Else
"May I ask their name?"
"May I ask where?"
Incident Information
“Now I will be asking you a few questions about the incident you are calling about today”
"When did the incident happen?"
*
/
Month
/
Day
Year
Statute of Limitations Date
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Month
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Day
Year
Date
"Do you recall what time it was?"
*
Yes
No
Time
*
AM
PM
AM/PM Option
"What type of case is this? For example, personal injury, employment, worker’s comp. or something else?"
*
Please Select
Personal Injury
Employment
Worker's Compensation
Other
"Which best describes the incident?"
*
Please Select
Motor Vehicle Collision
Slip and Fall
Dog Bite
Medical Malpractice
Other
"What was your role at the time of the incident?"
Please Select
Driver
Passenger
Pedestrian
Bicyclist
Other
"Where did the incident occur? And please be sure to let me know the street or intersection, city and state”
*
IF NOT a car accident please ask for the name and address of the premises
“In your own words, please describe what happened”
*
You are aiming for example: “Accident occurred southbound on Veteran Ave near the intersection of Wilshire Blvd. I was driving straight through a green light in lane number 2 and was struck from behind.” If the client is brief, get more details: “What were you doing right before the accident?” “Which direction were you traveling?” “Did you have a green light, stop sign, or any traffic control?” “How did the other vehicle or person make contact with you?” “From which direction were you hit (front, rear, side)?”
“What parts of your body were injured as a result of the incident?”
*
"Have you seen any medical providers as a result of this incident?”
*
No
Yes
“Which medical provider(s) did you see as a result of this incident?”
*
"What are your current symptoms, if any? And do you have any disabilities we should be made aware of?
*
If NONE, type "NONE"
"Were there other occupants in your vehicle at the time of the incident?"
*
Yes
No
"What are their names and relationship to you? Do you know if they were injured?"
"Was there a death involved in the incident?"
*
Yes
No
"I am very sorry to hear that. Who passed away and how?"
"Were you insured at the time of the incident?"
*
Yes
No
Unsure
"What is the name of the Insurance Company?"
*
"Do you have the policy number to provide to me?"
*
If no, please type in "No"
"Did you get the insurance information of the other party/parties involved?"
*
Yes
No
"Who was the insurance carrier for the other party/parties?"
"Was a rideshare or delivery service involved? For example, Uber, Lyft or food delivery"
*
Yes
No
"What company was it?"
*
Submit
Should be Empty: