• Bearstone Law's Case Evaluation Form

  • Instructions:

    Welcome to Bearstone Law, PLLC's Case Evaluation Form!

    Please fill out the form to the best of your knowledge and recollection. The more information and detail you provide, the better. However, there is no expectation that you go dig through your file cabinet or go seek out the information requested. It is sufficient to go by memory and whatever information and documents that are readily accessible. You will notice that the form asks for a lot of information, but the majority of the fields are not strictly required in order to submit. It is designed to get into the weeds but remains flexible enough to accomodate those who are in a rush. 

    Timeline:

    After you submit the form, an attorney at the firm will personally review it and determine whether your case is something the firm would be able to take on. We typically try to respond within one week at the most and often respond the same day. Your patience is appreciated, but if you are curious about the status, we welcome a call or email to check in.

    Thank you for taking the time, and we look forward to evaluating your claims.

  • Your Contact Information

    (for the person filling out the form)
  • Format: 000-000-0000.
  • Format: 000-000-0000.

  • By providing a telephone number and submitting this form, you are expressly consenting to Bearstone Law, PLLC, contacting you via SMS or MMS text message at the number provided above regarding appointment reminders or other case matters. Message frequency varies; message and data rates apply. For help, reply HELP or email contact@bearstonelaw.com. To opt out, reply STOP. The firm's Privacy Policy is available online at https://bearstonelaw.com/privacy.

    Further, you understand that simply submitting this evaluation form does not create an attorney-client relationship with the Firm, and that such relationship is not created unless and until you and the Firm both execute a written engagement agreement.

    Finally, you further consent to the Firm's limited use and disclosure of your data and personal case information in the ordinary course of the Firm’s business. By way of example only, the Firm may disclose certain of your confidential personal information to the Firm's technology vendors, such as cloud-service providers, data storage and cybersecurity vendors, document-management systems, billing and payment processors, and/or online platforms that aggregate marketing and advertising analytics data (e.g., Google Ads, Analytics, etc.).

    The Firm will take reasonable measures to ensure that the information submitted through this form is transmitted, used, and stored in a manner that preserves confidentiality, attorney-client privilege, attorney work-product, and other available protections to the fullest extent possible, and any use or disclosure of it will be limited to the minimum information reasonably necessary to accomplish the Firm's intended business purpose, including anonymizing or encrypting personal data.

  • How You Found Us

    This helps us to understand what brought you here and to thank anyone who referred you.
  • What most influenced your decision to contact us today?*
  • Did someone specifically recommend or refer you to the firm?*
  • Before contacting us, did you look us up online?
  • Where did you look us up?

  • Identity Verification

    Texas attorneys have an ethical duty to verify and confirm the identity of the people they represent. To satisfy that duty and to protect you from fraud, please provide your driver's license details and two quick photos below. This information is used solely to confirm your identity and is kept strictly confidential.
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  • Your Legal Claim Type

    Bearstone Law, PLLC, is plaintiff's law firm, which organizes its law practice by type of claim (roughly speaking). Please review the options below and choose the type of claim that most aligns with your circumstances. Your choice will tailor this form to include only those questions that are most relevant to your claim. If your circumstances implicate multiple claim types, just pick one of the primary claims and go with it. There is substantial overlap, and the general information gathered is the same regardless of claim type (so don't worry about it).

  • About Your Personal Injury Claim

  • Select the category that best fits the nature of the injury
  • Date and time of the incident or injury
     / /
  • Were police involved?
  • Were there witnesses?
  • Did you miss work because of this?
  • Did the injury leave you permanently disabled (e.g., paralyzed, amputation)?
  • Did you go to the hospital or urgent care facility?
  • Were you transported by ambulance?
  • In terms of permanent or long-term effects (i.e., will last longer than one year), check all that apply to your circumstances:
  • Do you have health insurance that covers treatment for the injury?

  • About Your Medical Malpractice Claim

  • Date of treatment/procedure
     / /
  • Date you first realized treatment/procedure was botched
     / /
  • Was a corrective procedure performed or treatment provided?
  • Are there any ongoing complications or remaining issues?
  • Did the patient pass away?
  • Date of death (if applicable)
     / /

  • About Your Insurance Claim

  • Date of loss
     / /
  • Have you filed a claim with the insurer?
  • Date claim filed
     / /
  • Do you believe the insurer handled your claim or otherwise acted in bad faith?
  • Is there a mortgage or loan secured by the property?
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  • About Your Other Civil Claims

  • Does this dispute/incident relate to a contract or agreement?
  • Date of the event/dispute/breach
     / /
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  • Has any lawsuit or any other proceeding already begun?
  • Are you aware of any upcoming hearings, statute of limitations, or any other deadlines?
  • Date of soonest deadline (if any)
     / /

  • About Your Wrongful Death Claim

  • Decedent's Date of Birth
     / /
  • Date of the incident
     / /
  • Date of death
     / /
  • Do you expect to serve as executor or personal representative of the estate?
  • Did the decedent have a will?
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  • Are any of the beneficiaries minors?
  • Has a probate proceeding been started?
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  • About Your Nursing Home Claim

  • Are you the person who was harmed by the nursing home / assisted living facility (i.e., the "Resident" for purposes of this form)?
  • Move-in Date
     / /
  • Move-Out Date
     / /
  • Is the Resident still living at the facility?
  • Date the Resident's injuries, neglect, or abuse were first noticed?
     / /
  • Were there any eye-witnesses?
  • Has the Resident passed away?
  • Date of Death (if applicable)
     / /
  • Has the facility been reported to the state or any agency?

  • About Your Auto Claim

  • Date of collision
     / /
  • What has this trip for?
  • Was a traffic ticket issued?
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  • Was a police report issued?
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  • Did you go to the hospital?
  • Were you transported by ambulance?
  • Were any airbags deployed?
  • Were you wearing your seatbealt?

  • About Your Employment Law Claim

  • Employment Start date
     / /
  • Employment End date (if applicable)
     / /
  • Earliest date of misconduct
     / /
  • Most recent misconduct
     / /
  • Did you report it to the employer or HR?

  • About Your Contract Claim

  • Date of the contract or agreement
     / /
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  • Date of breach
     / /
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  • Has a lawsuit or arbitration begun?
  • Is there a deadline or court date you are aware of (e.g., statute of limitations)?
     / /

  • About Your Worker's Compensation Claim

  • Date of injury
     / /
  • Did you report the injury to your employer?
  • Date reported to employer
     / /
  • Did you receive medical treatment?
  • Were you given a choice of physician?
  • Are you currently receiving any benefits or indemnity?
  • Last day of employment
     / /
  • Return-to-work date (if any)
     / /
  • Were you drug tested after the injury?
  • Did you pass the drug test? (if any)

  • About Your Product Liability Claim

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  • Date purchased
     / /
  • Date of the incident
     / /
  • Did you go to the hospital or urgent care facility?
  • If so, were you transported there by an ambulance?
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  • Did you deviate from the instructions or modify the product in any way?

  • A Few Final Questions

    . . . about liability, causation, and damages.

  • Liability & Causation

  • Thinking about the situation fairly, how would you say your responsibility compares to others who may have contributed to your loss/injury?

  • Damages (Past & Future)

  • Did you lose income/wages/profits?

  • Evidence

  • Rows

  • Miscellaneous

  • Is there a deadline or court date you are aware of?
     / /
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  • Should be Empty: