Personal Injury Intake Form

Tell us about the accident. Our legal assistant will follow up to schedule a free consultation with the attorney.

Before you submit

Submitting this form does not create an attorney-client relationship, and the attorney cannot represent you until the office confirms in writing. Time limits may apply to your matter, so please do not delay seeking advice. Do not include Social Security, passport, A-number, bank or card numbers.

Your contact information

Full name

Phone number

Email address

Preferred language

Best way to reach you

Best time to reach you

How did you hear about our office?

About the accident

Date of accident

Where did it happen? (city and state)

Type of accident

Were you injured?

Have you received medical treatment?

Was a police report made?

Your auto insurance company (if any)

Other driver’s insurance company (if known)

Have you already hired another attorney for this accident?

Briefly describe what happened and your injuries

I understand that submitting this form does not create an attorney-client relationship and that I should not include highly sensitive identification numbers.