Activity-Wellness Check

Activity-Wellness Check
CLIENT INFORMATION
Client's Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Preferred Method of Contact:
Type of Investigation:
How many days of surveillance are requested?
Priority Level:
Activity / Wellness Check (Adult) Section
Requestor/Client Name:

First NameLast Name
Subject's Name:

First NameLast Name
Subject's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subject's Phone Number:
Please enter a valid phone number.
Subject's DOB:

MonthDayYear
Date
Sex:
Race:
Weight:
Height:
Hair Color:
Date of Injury: (if applicable)

MonthDayYear
Date
Type of Claim: (if applicable)
Employer:
Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone Number:
Please enter a valid phone number.
Employer's Email:
example@example.com
Case Manager / Assigner / Company (if applicable):
Case Manager Name: (if applicable)

First NameLast Name
Case Manager's Phone Number: (if applicable)
Please enter a valid phone number.
Case Manager's Email: (if applicable)
example@example.com
Budget:
City/State:
Due Date or Deadline: (if known)

MonthDayYear
Date
Assignment Instructions:
(Describe the objectives, concerns, or focus areas of this check.)
Key Aspects of Adult Activity / Wellness Checks

Our investigators discreetly assess:

Wellness: Physical and mental condition of the subject
Safety Check: Environmental hazards and home safety
Social Interaction: Companionship and engagement levels
Reporting: Clear documentation and updates to family, insurer, or healthcare provider
Child Activity / Minor Activity Check Section
Is the individual to be investigated a minor?
Do you consent to video documentation to confirm or exclude your suspicions?
Child's Name:

First NameLast Name
Nicknames:
Child's DOB:

MonthDayYear
Date
Gender:
Child's Email: (if applicable)
example@example.com
Child's Phone Number:
Please enter a valid phone number.
Current Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Address: (for surveillance if difference)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Information:
Grade:
School Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Information: (if applicable)
Position: (If applicable)
Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vehicle Information: (if applicable)
Year, Make, Model, Color, License Plate
Known Friends / Family / Associates:
Please list friends, family, associates
Social Media Profiles:
Provide profile links, usernames, or handles
Purpose of the Investigation:
Describe your concerns or suspicions
What specific information are you hoping to learn or confirm?
Would you like observation on specific days or times?
Additional Notes:
If you have a photo of the individual, please upload here:

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Legal Eye Investigations Statement:

Legal Eye Investigations, LLC is committed to providing ethical, discreet, and lawful investigations. All reports, photos, videos, and invoices are delivered through our secure case management system. We comply with all Maryland state and federal privacy laws.

Authorization:
By submitting this form, you acknowledge that you are the authorized party requesting this investigation and consent to Legal Eye Investigations, LLC conducting the necessary surveillance or verification work in accordance with Maryland law.
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: