Client Intake Questionnaire (Personal Injury)

1. Client Information

• Full legal name:
• Preferred name/pronouns:
• Date of birth:
• Social Security Number/Tax ID (if needed):
• Residential address:
• Mailing address (if different):
• Primary phone:
• Alternate phone:
• Email address:
• Preferred communication method (phone/email/portal/text): Text messaging may not be confidential.

2. Emergency Contact

• Name:
• Relationship to client:
• Phone number:
• Email address:

3. Incident Overview

• Date of incident:
• Time of incident:
• Location (address and city/state):
• Type of incident (check all that apply):
• ☐ Auto accident
• ☐ Truck/commercial vehicle
• ☐ Motorcycle/bicycle
• ☐ Pedestrian
• ☐ Slip and fall/premises
• ☐ Dog bite/animal attack
• ☐ Product defect
• ☐ Medical negligence
• ☐ Workplace injury (third-party claim)
• ☐ Other: ________________________
• Brief description of what happened (who, what, where, how):
• Weather/lighting/road conditions (if applicable):
• Were you cited or charged? ☐ Yes ☐ No
• If yes, details:

4. Parties Involved

• At-fault party name(s):
• At-fault party contact information:
• Vehicle owner/driver/employer (if different):
• Property owner/manager (if premises case):
• Manufacturer/seller/distributor (if product case):
• Medical provider/facility (if medical negligence case):

5. Insurance Information

• Your auto insurance (if applicable): carrier, policy number, claim number:
• At-fault party insurance: carrier, policy number, claim number:
• Uninsured/underinsured motorist coverage: ☐ Yes ☐ No ☐ Unknown
• MedPay/PIP coverage: ☐ Yes ☐ No ☐ Unknown
• Health insurance: carrier, policy number:
• Other applicable insurance (homeowner, umbrella, workers' comp):

6. Police/Incident Reports

• Responding agency:
• Report number:
• Officer name/badge:
• Were photos or body cam taken? ☐ Yes ☐ No ☐ Unknown
• Were any citations issued? ☐ Yes ☐ No ☐ Unknown

7. Injuries and Symptoms

• Injured body parts:
• Symptoms (pain, numbness, headaches, dizziness, etc.):
• Did you lose consciousness? ☐ Yes ☐ No ☐ Unknown
• Did you go to the ER? ☐ Yes ☐ No
• Date and facility:
• Ambulance transport? ☐ Yes ☐ No
• Diagnostic imaging (X-ray/CT/MRI): ☐ Yes ☐ No
• Dates and facilities:

8. Medical Treatment

• Primary care provider:
• Specialists (orthopedic, neuro, pain management, etc.):
• Physical therapy/chiropractic:
• Surgery recommended or performed? ☐ Yes ☐ No
• If yes, details and dates:
• Current treatment status:
• Medications and prescriptions:
• Future treatment recommendations:

9. Prior Medical History

• Prior injuries to same body parts? ☐ Yes ☐ No
• If yes, describe and dates:
• Pre-existing conditions (if any):
• Prior surgeries:
• Prior similar claims or accidents:

10. Employment and Lost Wages

• Employer name and address:
• Job title and duties:
• Work schedule:
• Rate of pay (hourly/salary):
• Time missed from work (dates and total days):
• Reduced duties or restrictions:
• Loss of benefits/bonuses/overtime:

11. Property Damage and Out-of-Pocket Costs

• Vehicle/property damage description:
• Repair estimates or invoices:
• Rental car expenses:
• Towing/storage costs:
• Medical bills paid out-of-pocket:
• Other expenses (travel, parking, home care, etc.):

12. Witnesses and Evidence

• Witness names and contact information:
• Photos/videos available? [ ] Yes [ ] No
• Dashcam/surveillance footage? [ ] Yes [ ] No [ ] Unknown
• Social media posts related to incident? [ ] Yes [ ] No

13. Prior Claims and Litigation

• Prior personal injury claims or lawsuits? ☐ Yes ☐ No
• If yes, list dates and outcomes:
• Prior insurance claims (auto, health, disability):

14. Documents and Uploads

• ☐ Police/incident report
• ☐ Photos/videos
• ☐ Medical records and bills
• ☐ Insurance policy declarations
• ☐ Claim correspondence
• ☐ Repair estimates/invoices
• ☐ Wage loss documentation
• ☐ Other supporting documents: ________________________

15. Additional Information

• Desired outcome:
• Deadlines or upcoming hearings:
• Any concerns not covered above:
• How did you hear about our firm?

16. Acknowledgement

• I certify that the information provided is accurate to the best of my knowledge and understand that submission does not create an attorney-client relationship until a written engagement agreement is signed.

Client signature: ____________________________ Date: __________

Intake received by (staff): ____________________ Date: __________