Auto Accident

Intake Questionnaire

Thank you for taking the time to complete our auto accident client intake questionnaire. We understand that there are quite a few questions, but each one is essential in helping us fully understand the details of your legal issue.

The information you provide allows us to connect you with an attorney who has the specific experience and expertise required to address your unique situation effectively. Your thorough and honest answers will enable us to serve you better and ensure that you receive the best possible representation.

Name

First Name

Last Name

Phone

(###)

###

####

What is your address?

What is your marital status?

What is your current income level? Low, medium, or high?

Are you currently employed? If so, what is your profession?

What is your race?

What was the date of your accident?

YYYY

In what city and state did the accident occur?

Can you describe what happened?

Please be as detailed as possible.

Did anyone die in this accident?

What type of accident?

Were the police notified?

Did the police file an accident report?

Were you at fault for causing the accident on the police report?

Yes, I was at fault.

No, I was not at fault.

What were your injuries? Describe in detail.

Were you transported to the hospital by an ambulance or helicopter?

Did you receive medical treatment for your injuries?

Are you currently undergoing medical treatment for your injuries?

Do you have auto insurance?

Did you file an insurance claim?

Was your vehicle damaged in the accident?

Describe the damage to your vehicle.

Do you believe the other driver was at fault for causing this accident? Explain why in detail.

Was the other driver insured?

Have you already contacted an attorney? If so, please provide their name.

What is the emotional impact this accident has had on you?

What is the financial impact this accident has had on you?

What outcome are you hoping to achieve by pursuing this case?

Auto Accident

Intake Questionnaire

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