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Personal Injury Case Intake

Section 1 — Contact Info

Full Name

*

Phone Number

*

Email Address

*

Section 2 — Accident Basics

What type of accident occurred?

*

What type of accident occurred?

A

Car accident

B

Truck accident

C

Motorcycle accident

D

Slip and fall

E

Workplace injury

F

Other

When did the accident occur?

*

Where did the accident happen?

*

Section 3 — Case Indicators

Were police involved?

*

Were police involved?

A

Yes

B

No

Did you receive medical treatment?

*

Did you receive medical treatment?

A

Yes

B

No

Is an insurance company involved?

*

Is an insurance company involved?

A

Yes

B

No

Section 4 — Description

Please briefly describe what happened

*

Section 5 — Urgency

How soon do you need legal help?

*

How soon do you need legal help?

A

Immediately

B

Within a few days

C

Just exploring options

Upload photos or documents

*

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