Intake Form Personal Injury

First name

Middle name

Last name

Your Birthday

Defendant's [company] name and address

If you own any legal entity, your company name and address

Your position with your company, if any

Email

Phone

Your Home Address

You Work Address, if any

Your company, if any, is

For-Profit

Non-Profit

Newly formed non-profit, 501(c)(3) status is pending

Marital Status

Minor children's names and ages

Employer

Employer's Address

Your position and salary

When accident occurred?

Where injury occcured?

Please describe all of your injuries:

If you didn’t go in an ambulance to the hospital/ER immediately, did you seek medical attention? If so, please list the name of the facility and the date you went for treatment:

Are you still in pain from the accident? If so, please describe:

Has your life changed in any other way? Are you unable to do things you used to enjoy before the accident?

Please name all cities, counties, states releated to your case

Was this a work related accident?

Yes

No

Please describe your case

Who do you believe is responsible for your injuries?

Please list documents/evidence you have gathered so far to prove your case, if any

Have you already spoken with another attorney about this case? If so, please give their name and contact information

Are you still working with this attorney?

Has an attorney previously declined to represent you in this matter? If yes, why?

Please provide names of cases (i.e. "John Green v. Consumer Goods Inc."), and courts where you, your company (if you own a company), members of your company have litigate(d) any matters, or a pre-litigation settlements were achieved, if any

Do you use any instant messengers?

Signal

Slack

Watsapp

I DECLARE THAT I PERSONALLY ANSWERED THE ABOVE QUESTIONS TRUTHFULLY AND ACCURATELY TO THE BEST OF MY KNOWLEDGE. I ACKNOWLEDGE THAT FAILURE TO PROVIDE TRUTHFUL RESPONSES MAY NEGATIVELY IMPACT MY CASE

I have read and understood the Disclaimer page, Privacy Policy page, and agree with the terms.

I understand that this form serves for evaluation, is not a retainer. I understand that a formal, written, comprehensive (minimum 5 pages long) fee agreement should be entered to be represented by Poulsen Law P.C.. I understand that, before entering a written agreement with Poulsen Law P.C., any reliance on the information contained in this correspondence or any preceeding or follow-up communication with anyone at Poulsen Law P.C., is taken at my own risk.

Intake Form- Personal Injury

We are delighted to have an opportunity to evaluate your case. Please fill out the form to the best of your knowledge and we will review and evaluate your legal claim.

Thank you for considering Poulsen Law, we are looking forward to working on your case.

Intake Form- Personal Injury

We are delighted to have an opportunity to evaluate your case. Please fill out the form to the best of your knowledge and we will review and evaluate your legal claim. Thank you for considering Poulsen Law, we are looking forward to working on your case.

We are delighted to have an opportunity to evaluate your case. Please fill out the form to the best of your knowledge and we will review and evaluate your legal claim.

Thank you for considering Poulsen Law, we are looking forward to working on your case.