Client Intake Form Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Social Security Number Best Method to Reach You Best Times to Reach You Marriage Status Married Single Divorced Number of Children If married, spouses name On What Date Did Your Injury Occur? MM slash DD slash YYYY Approx. time of injury Where Did Your Injury Occur? City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Did Your Injury Occur? Aircraft accident Animal bite or attack Assault and battery Defective premises Defective product Police negligence Medical malpractice Motor vehicle accident Slip or trip and fall Water-related accident Other Were you transported by an ambulance? Yes No Name of Ambulance Company, if known Was a police/accident report taken? Yes No If yes, please provide copy and/or the report number, if known:      Max. file size: 50 MB.Report number if known Do you have health/medical insurance? Yes No (Please provide a copy of the front and back of your medical insurance card)Max. file size: 50 MB.Do you have Medi-Cal or Medicare? Yes No (Please provide a copy of the front and back of your medical insurance card)Max. file size: 50 MB.Do you have car insurance? If so, please provide NAME, POLICY # (Please provide a copy of your car insurance Declaration page)Max. file size: 50 MB.If applicable, your car insurance’s UM/UIM Coverage (uninsured/underinsured motorist) Describe how your injury occurredDescribe your injury(ies).List all doctors and other health care providers who have treated your injuries, including their names, addresses, and telephone numbers. (Please provide a copy of ALL medical provider’s visit summary and/or discharge papers)FileMax. file size: 50 MB.Are you still seeking medical treatments and/or therapy? If so, list all doctors and other health care providers you are currently treating with regarding your injuries, including their names, addresses, and telephone numbers.      Have you lost income as a result of your injuries? Yes No (please provide a copy of 4 payroll stubs prior to the accident)File 1Max. file size: 50 MB.File 2Max. file size: 50 MB.File 3Max. file size: 50 MB.File 4Max. file size: 50 MB.Income before injury Income after injury Employer Position Employer’s address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you currently working? Yes No Expect to return to work? Yes Will Not Return to Work Describe any other ways in which your life has changed as a result of your injuries. (For example, you are no longer able to engage in athletic activities, your appearance has changed, you cannot care for your children, etc.)If married, has your spouse experienced any losses as a result of your injury? If so, describe.List the names, addresses, and phone numbers of any possible witnesses in your case.