Intake Questionnaire

Date of Intake *

First Name *

Last Name *

Client Date of Birth *

Male/Female *

Client Full Address *

Best Time to Reach the Client *

Home Phone

Cell Phone *

Email *

EMERGENCY CONTACT INFORMATION

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

ACCIDENT DETAILS

Date of Accident *

Time of Accident *

Day of Accident *

Type of Accident *

Working/On the Clock During accident *

Street(s) Accident Happened On *

City Accident Happened In *

State Accident Happened In *

County Accident Happened In *

Do you have any of the following? *

How many vehicles were involved? *

Were the Police called? *

If you know the accident number and/or officer name, please list.

Did the police hand out any tickets? *

Did the police arrest anyone at the scene? *

Description of the Accident. *

Please select all that apply to the accident. *

Please select the position of the person if they were in the car.

INJURY DETAILS

List out the type of injuries. *

Did they take an ambulance to the hospital? *

Were they treated on scene by EMS? *

Admitted overnight to the hospital for injuries? *

Date of Original Treatment? *

Name of Facility where treated. *

Address of Facility where treated. *

CLIENT INSURANCE

Name of No-Fault Insurance Company (Example: Geico, Progressive, etc) *

Does the insurance policy have $50k defendant/bodily injury/liability coverage? *

File already with the insurance company? *

Funnel designed by Viribuz Media