Hendrick & Henry Law

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Client Intake Form

"*" indicates required fields

Client Name:*

First Last

Client Email

Social Security #*

Client Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Marital Status:*

Date Of Birth*

Home Or Mobile Phone:*

Work Phone:

Person To Notify In Case Of Emergency:

Relation?

Emergency Contact Primary Phone:

Emergency Contact Work Phone:

Employers Name:

Employers Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Who Referred You To This Office?

Date Of The Incident:*

Time Of Incident

Specific Time (If Known):

Short Description Of Problem

Describe Clients Legal Problem and Injuries:*

Have You Consulted Another Attorney?

Attorney Name (If Contacted):

List All Witnesss You Have Regarding Your Legal Problem (Including Contact Information):

Have You Sought Medical Treatment?

Where Have You Sought Medical Treatment?

Do You Have Visible Injuries?

Do You Have Pictures?

Do You Have Health Insurance?

Health Insurance Provider

Primary Health Insurance

Secondary Health Insurance

Transported By Ambulance?

Ambulance Company Name:

Disregard This Section If The Injury Did Not Involve A Motor Vehicle

Auto Insurance Company Name

Auto Insurance Policy Number

List All Previous Collisions

List All Drivers In The Home, Their Auto Insurance Company and Insurance Policy Number

Responding Police Department

Case Number

Intake Form Completed By:

Person Filling Out Intake Form*

Attorney Assigned To

Notes for Team

Human Verifcation*

Please check box if you are human