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Intake Questionnaire

Sample Injury Intake Questionnaire

Life for an injury victim often times becomes much more difficult after the injury. Not only does the victim suffer physically (and possibly mentally) as a result of an injury, but now the victim or a representative must deal with doctors, insurance companies and possibly attorneys. Each will require the victim or a representative to provide them with documentation. If you are the person providing the documentation, filling in the form below will prepare you for most of the questions these individuals need answered.

Please use the following form to submit information or print the form and fax or mail or bring in to the address shown on this page.

All information gathered is kept confidential.

Postal Address	John H. Carney & Associates One Meadows Building 5005 Greenville Avenue, Suite 200 Dallas, Texas 75206
Telephone	(214) 368-8300
Toll Free	(866) 368-8346
Fax	(214) 363-9979

Personal Information
Name: *		Date of Birth:
E-mail: *		Social Security No.:
Address:*		City:
		State:
		Zip:
Home phone:*		Best method to reach you:
Work phone:		Best times to reach you:
Mobile:
Married Single Divorced If married, spouse's name:
Number of children:

Injury Details
On what date did your injury occur?*
Where did your injury occur?	City State
How did your injury occur?	Other Specify
Describe how your injury occurred:
Who do you believe caused or is responsible for your injury, and why?
Describe your injury(ies):
List all doctors and other health care providers who have treated your injuries, including their names, addresses, and telephone numbers:
Total medical expenses incurred to date for your injuries:	$
Total medical expenses you expect to incur in the future:	$
List the names, addresses, and telephone numbers of all insurance companies that may be involved (including, as applicable, automobile insurer, health insurer, disability insurer, homeowner's insurer, etc.):
Have you lost income due to your injuries?	Yes No If yes, amount of lost income $
Income before injury:	$ per
Income after injury:	$ per
Employer:
Position:
Employer's Address:
City:
State:
Zip:
Employer's telephone number:
Are you currently working?	Yes No
Expect to return to work on?
Will not return to work	Yes No
Are you in pain? If so, describe
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.
Have you previously consulted an attorney regarding your case?	Yes No
If yes, provide the attorney's name(s), the firm name(s), the address(es), and the telephone number(s).
Is your relationship with the attorney ongoing?	Yes No
Has an attorney declined to represent you in this matter?	Yes No
If yes, why?
Questions you have about your case:*

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