Intake Form
Complete this form to help us evaluate your case. Submitting it does not guarantee that we will accept your case.
Client Information
First Name
*
Middle Name
Last Name
*
Date of Birth
-
Month
-
Day
Year
Date
What is your marital status?
Single
Married
Separated
Divorced
Widowed
Spouse's name
Preferred Language
Please Select
English
Spanish
Street Address
Apt / Unit
City
State
ZIP Code
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
☎
Call Us
🌐
Webpage
Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred contact method
*
Phone call
Text message
Email
Incident Details
Type of incident
*
Car accident
Motorcycle accident
Truck accident
Slip / trip and fall
Other
If other, please describe
Date of incident
*
-
Month
-
Day
Year
Date
Time of incident
Hour Minutes
AM
PM
AM/PM Option
Location (address, intersection, or business name)
County where it occurred
Describe how the incident happened
Motor Vehicle Accident Details
Your role
Driver
Passenger
Pedestrian
Cyclist
Number of vehicles involved
Did police respond and create a crash report?
Yes
No
Crash report number (if known)
Were you cited or ticketed?
Yes
No
Your auto insurance company
Other driver's insurance (if known)
Were you driving a work or company vehicle?
Yes
No
Slip / Trip and Fall Details
Where did the fall occur?
Name of property owner or business
What caused the fall?
Was an incident report filed with the business?
Yes
No
Were there any witnesses?
Yes
No
Injuries and Medical Treatment
Were you injured?
Yes
No
Describe your injuries
Did you receive medical treatment?
Yes
No
Where did you receive treatment?
ER / Hospital
Urgent care
Primary doctor
Chiropractor
Specialist
Other
Are you still treating?
Yes
No
Where are you treating?
Do you have health insurance?
Yes
No
What is the name of your health insurance company?
Do you have Medicare, Medicaid, or both?
Medicare
Medicaid
Both
Did you miss work because of the incident?
Yes
No
Approx. days/weeks of work missed
Legal History and Insurance
Have you hired or spoken with another attorney about this?
Yes
No
What is the attorney's name?
Have you reported the accident to your insurance company? (auto accidents only)
Yes
No
Insurance company and claim information
Have you been contacted by an insurance company?
Yes
No
Insurance company / adjuster / claim number
Have you given a recorded statement to any insurance company?
Yes
No
Has any insurance company offered a settlement?
Yes
No
How did you hear about us?
Referral
Internet / Google
Social media
Returning client
Other
If Other, how did you hear about us?
Referred by (name)
Submit
Should be Empty: