← Free law firm client intake forms

Personal injury client intake form

A free intake form for personal injury firms. Part 1 is the form a new client fills in: post it on your website, send it as a PDF, or hand it over in the office. Part 2 is the questions your intake staff should ask next, because a form's answers often point to something the form can't ask about.

Print this page, or save it as a PDF from your browser's print dialog. Change it to fit your firm and your state.

This is a template, not legal advice. Deadlines and notice rules differ by state and by who the claim is against.

Part 1: The client form

About you

  • Full name: ____________________
  • Phone: ____________________ Email: ____________________
  • Best way and time to reach you: ____________________
  • Mailing address: ____________________
  • Date of birth: ____________________
  • Are you filling this in for someone else? ☐ No ☐ Yes. Your name and your relationship to them: ____________________

What happened

  • Date it happened: ____________________
  • Time it happened: ____________________
  • Where it happened (address, intersection, or business name): ____________________
  • In your own words, what happened, in the order it happened: ____________________
  • What were you doing just before it happened? ____________________
  • What caused your injury? ____________________

Who was involved

  • Who do you think is responsible? List each person, business, or agency, and why you think so: ____________________
  • Did it happen at a business, a store, or someone's property? ☐ No ☐ Yes. Which one: ____________________
  • Was a government vehicle, government property, or a government employee involved? This includes city buses, public sidewalks, and public schools. ☐ No ☐ Yes ☐ Not sure
  • Were there witnesses? ☐ No ☐ Yes. Their names and how to reach them: ____________________

Your injury and treatment

  • What was hurt? ____________________
  • What did a doctor tell you is wrong? ____________________
  • Where have you been treated? List each hospital, clinic, or doctor: ____________________
  • Are you still being treated? ☐ No ☐ Yes
  • Did you have an injury or condition in the same part of your body before this? ☐ No ☐ Yes. Please describe: ____________________

Your losses

  • Medical bills so far, if you know: ____________________
  • Who has paid them (your health insurance, the other side's insurance, you, not yet paid): ____________________
  • Have you missed work because of the injury? ☐ No ☐ Yes. About how much time and pay: ____________________
  • How has the injury changed your daily life? ____________________

Insurance and claims

  • Has an insurance company contacted you? ☐ No ☐ Yes. Which one: ____________________
  • Have you given a recorded statement to any insurance company? ☐ No ☐ Yes ☐ Not sure
  • Have you been offered money? ☐ No ☐ Yes. How much: ____________________
  • Have you signed anything about this? ☐ No ☐ Yes. What: ____________________
  • Have you filed a claim, a notice, or a lawsuit? ☐ No ☐ Yes. When: ____________________
  • Have you talked with another lawyer about this? ☐ No ☐ Yes

Records and evidence

  • Was a police report or incident report made? ☐ No ☐ Yes ☐ Not sure. Report number, if you have it: ____________________
  • Do you have photos or video? ☐ No ☐ Yes
  • Were there security cameras where it happened? ☐ No ☐ Yes ☐ Not sure
  • If a product, an animal, or a vehicle caused the injury, where is it now? ____________________

Anything else

  • Is there anything else we should know? ____________________
  • How did you hear about us? ____________________

Sending this form does not make this firm your lawyer. The firm will contact you to talk about whether it can help.

Part 2: The questions to ask next

A form takes the answer it gets. These are the questions to ask when an answer is thin, or when it points to something the form didn't ask. Each one starts from an answer on the form.

Deadlines

  • A government body may be involved. Ask which agency or public employee, and whether anyone has filed a written notice of claim. Claims against government bodies often need a written notice within months, well before the usual deadline to sue.
  • The client learned of the injury or its cause later than the date it happened. Get both dates. The later date can start the deadline.
  • A claim, notice, or lawsuit was filed. Get the date it was filed, and who filed it.
  • The injury happened a long time ago. Get the exact date, and flag it to an attorney the same day.

Who is at fault

  • It happened at a business. Ask which business the client was dealing with. Ask whether they saw anyone cleaning, repairing, or maintaining what caused the harm, such as a cleaning crew or a contractor. Who owns or insures the property comes from your records search, so don't ask the client unless someone told them firsthand.
  • More than one party may be at fault. Ask the client to name each one, and why they blame each one.
  • A product caused the injury. Get when and where it was bought, its make and model, and whether it still exists.

The client's own part

The other side will look for something the client did. Ask about it plainly now, so the attorney hears it first:

  • What the client was doing, and where their attention was, at the moment it happened.
  • In a fall: what they had on their feet.
  • Any gap between the injury and the first treatment, and the reason for it.
  • Any delay in reporting the injury, and the reason for it.
  • Alcohol, drugs, or medication, only where your firm asks and the matter may turn on it.

The injury and the losses

  • An earlier injury to the same body part. Ask when, how, and what treatment it had. The other side will say the old injury caused the harm.
  • Treatment is continuing. Ask what is planned next and who ordered it.
  • Someone else paid the medical bills. Ask who. A health plan or a hospital may hold a lien on any recovery.

Insurance

  • The client spoke with an insurance adjuster. Ask what they said, whether it was recorded, and whether they signed anything. Ask for a copy of anything they signed.
  • The client was offered money. Ask whether they accepted it, and whether they signed a release.

Evidence that may disappear

  • There may be camera footage. Ask whether anyone has asked for it yet. Businesses often record over footage, so it may not last.
  • A vehicle, a product, or a hazard caused the injury. Ask whether it still exists, who has it, and whether it has been repaired or changed.

Situations to handle with care

  • Someone died. Let the caller set the pace. Learn who the survivors are, and whether an estate has been opened.
  • The injured person is a minor. Learn who the parent or guardian is.
  • An assault or abuse. Ask whether the client is safe now, before you ask for details.

When the matter may be another area of law

  • Hurt at work: possibly a workers' compensation claim. A personal injury claim may still apply when someone other than the employer also caused the injury.
  • Hurt by police, at a jail, or at a public school: possibly a civil rights matter.
  • Hurt on a boat or a ship, or in an aircraft: maritime or aviation law may apply.
  • Charged with a crime over the same event: the client may also need a criminal defense lawyer.
  • No physical injury, only damaged property or lost money: not a personal injury matter.

Ask these questions without a form

Verantel asks these questions as an interview. It talks with the people who reach your firm, in plain language and in their own language, and asks the next question when an answer points to a deadline, a government claim, or evidence that may disappear. Then it hands your firm a structured record, with the interview line each fact came from. Verantel is not a lawyer and gives no legal advice.

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