Thank you so much for contacting my law office! Please read the privacy policy below, and then fill out this form as best as you can prior to our consultation. The purpose of this form is to help me evaluate your situation prior to our first meeting. Filling out this form is not an agreement that I will represent you. If you choose to hire me as your attorney, we will execute a separate engagement letter that will outline our respective responsibilities to each other.

Also, you should understand that I might learn information that would prevent me from representing you. For example, if you have a claim or adverse interest against an existing client, I have a professional and ethical obligation to avoid that conflict of interest.

If you have any concerns about the information sought herein, leave it blank and we can discuss those concerns at our first consultation. However, know that each item of information sought herein could be relevant to your legal situation.

If you are filling this form out on behalf of someone else, please input the potential client's information, not your own.

Privacy Policy

All information received from you is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 128-bit SSL encryption.

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

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Contact information

Preferred Contact Method:

Date of birth:

Are you (the potential client) under the age of 18?

Gender:

Driver's License Number:

Marital Status:

Are you currently employed?

How were you referred to my firm?

ACCIDENT INFORMATION

Were you the driver or passenger?

Date of Accident

Approximately what time did the accident occur?

Where did the accident occur?

Were the police called to the scene?

Was an accident report filed?

Describe how the accident occurred to the best of your ability.

Were any other people with you who were also injured in this accident?

Were there any other witnesses?

Did you give a recorded statement to anyone about this accident?

Injuries

Describe the injuries you suffered from the accident in detail:

Describe any injuries that other people with you endured:

Did anyone go to the hospital?

Was anyone transported by ambulance?

Were X-Ray's taken?

Is anyone still undergoing medical treatment?

Have you missed time from work due to your injuries?

Has anyone else missed time from work due to their injuries?

Do you have any photos of your injuries?

Do you have health insurance?

Property Damage

Is your vehicle still drivable?

Do you need help resolving the damage to your vehicle?

Estimated cost of damages:

Where is your vehicle located now?

Vehicle & Auto Insurance Information

What is the make, model, year and color of your vehicle?

License plate number and state:

Do you have clear title to your car?

Who is the record owner of your vehicle?

Do you have any photos of your car or the car you were in following the accident?

Do you have auto insurance?

Defendant's Information

Driver's Name:

Driver's contact telephone number:

Driver's Address:

Defendant driver's license number (if known):

Date of birth (if known):

What is the make, model, year and color of the other driver's car?

License plate number and state:

Does the driver of the other car, own that car?

Does the other driver have auto insurance?

Were there any passengers in the other driver's car?

ACKNOWLEDGEMENT AND ACCEPTANCE

THANK YOU!