Personal Injury Client Intake Form
Drafts a fillable intake form for prospective personal injury clients that supports conflict checking, statute-of-limitations tracking, case evaluation, and engagement setup.
Prerequisites
- Jurisdiction — state of incident and client residence (determines SOL, comparative fault rules, damage caps, no-fault requirements).
- Firm details — firm name, address, contact info, fee structure (contingency percentage, cost advancement policy).
- Documents already provided — accident reports, medical records, photos, correspondence — to pre-populate fields and generate follow-up questions.
Output Structure
Generate a fillable intake form with the following sections in order. Calculate and flag the statute-of-limitations deadline prominently at the top based on jurisdiction and incident type.
1) Client Identification
| Field | Notes |
|---|---|
| Full legal name | As on government ID |
| Former names / aliases | For conflict checking |
| Date of birth | |
| SSN (last 4 only) | Include privacy notice |
| Residential address | |
| Mailing address (if different) | |
| Marital status / spouse name | Loss-of-consortium relevance |
| Dependents (names, ages) | Wrongful death relevance |
2) Contact & Communication
| Field | Notes |
|---|---|
| Primary phone | Mobile / landline |
| Secondary phone | |
| Email (personal / work) | |
| Preferred contact method | Phone / email / text / portal |
| Do NOT contact at | Confidentiality concerns |
| Text/email consent | Security limitation warning |
| Authorized recipients | Others permitted case info |
| Interpreter / accommodation | Language or accessibility needs |
3) Incident Details
- Date of incident — flag SOL deadline (verify jurisdiction-specific period)
- Location — street address, city, county, state
- Type — motor vehicle, slip/fall, premises liability, product liability, medical malpractice, dog bite, workplace, other
- Narrative — client's own words, chronological
- Conditions — weather, road, environmental (if applicable)
- Police / incident report — report number, agency
- Witnesses — name, phone, relationship, observations
- Photos / video — scene, injuries, property damage
4) Parties Involved
For each opposing party and additional involved parties:
| Field | Details |
|---|---|
| Full name | |
| Role | At-fault driver, property owner, employer, manufacturer, etc. |
| Contact info / address | |
| Insurance carrier & policy # | If known |
| Attorney (if represented) | Name, firm, contact |
| Employer | If commercial vehicle / on-the-job |
| Relationship to client | Stranger, employer, landlord, etc. |
Ensure every named person/entity is captured for conflict-system intake.
5) Injuries & Medical Treatment
- Injuries sustained — body parts, diagnosis if known
- Ambulance transport — destination facility
- ER / urgent care — date, facility
- Treating physicians — name, specialty, facility, treatment dates
- Ongoing treatment — PT, scheduled surgery, pain management
- Pre-existing conditions — same body parts or related (critical for causation)
- Lost work days — dates, employer, wage rate
- Current symptom status — improving / stable / worsening
- Medical records authorization — HIPAA-compliant release attached
6) Insurance Information
| Type | Carrier | Policy # | Limits (if known) |
|---|---|---|---|
| Client auto | |||
| Client health | |||
| UM/UIM coverage | |||
| MedPay / PIP | |||
| At-fault liability | |||
| Homeowner's / renter's | |||
| Umbrella |
- Recorded statement given? — to whom, when (flag as red flag)
- Signed anything from opposing insurer? — flag immediately
Note: no-fault states require adjusted insurance sections [VERIFY jurisdiction].
7) Property Damage
- Vehicle year/make/model, current location
- Repair estimate or total loss determination
- Rental car status
- Personal property damaged
8) Prior Legal History
- Prior attorneys on this matter — name, firm, dates, reason ended
- Pending / prior litigation (past 10 years) — case, court, status
- Prior PI claims — critical for credibility and IME preparation
- Criminal history — may be discoverable
- Bankruptcy filings — affects claim ownership
- Family members with matters at firm — conflict check
9) Financial / Fee Discussion
- Employment status and occupation
- Income range (bracketed: <$25K / $25-50K / $50-100K / $100K+)
- Contingency fee explanation — plain-language description
- Cost advancement acknowledgment
- Lien awareness — Medicare, Medicaid, ERISA, workers' comp, child support
State that a separate written contingency fee agreement will follow if the firm accepts the matter. Do not include a fee agreement in the intake form.
10) Authorizations & Disclosures
Include with signature lines:
- No attorney-client relationship disclaimer — intake does not create representation
- Medical records authorization (HIPAA-compliant, separate signature)
- Employment records authorization
- Insurance records authorization
- Third-party communication consent
- Data privacy notice
- Text/email communication consent (with security warnings)
- Accuracy acknowledgment
Signature blocks: prospective client, intake attorney, date.
Guidelines
- Flag SOL deadline at top of completed form; verify jurisdiction-specific periods.
- Use plain language throughout — clients are often injured and stressed.
- Pre-populate from uploaded documents; generate specific follow-up questions for gaps.
- Capture all named persons/entities in conflict-check-compatible format.
- Note state-specific variations: no-fault insurance, pure vs. modified comparative fault, damage caps [VERIFY].
- Flag red flags early: prior recorded statements, signed releases, pre-existing conditions in same body part, approaching SOL.
- Formatting: minimum 11pt body, adequate white space, section headers, fillable fields.
- Use [VERIFY] for all jurisdiction-specific rules before finalizing.
Cross-references
- @demand-letter-personal-injury
- @medical-records-summary
- @contingency-fee-agreement
- @hipaa-authorization