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Personal Injury Intake Form Template

Create a streamlined process to gather client information effectively

Gathering information from potential clients can be overwhelming, especially when every detail counts in personal injury cases. This personal injury intake form template helps law firms collect essential facts effectively, ensuring nothing slips through the cracks. You can simplify your intake process, enhance client experience, and improve your case management-all while maintaining compliance with WCAG standards. Get started with this customizable form to turn inquiries into actionable insights that benefit your practice.

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Full name
Date of birth
Email address
Mobile phone
Preferred contact method
Phone call
Text message
Email
No preference
Date of incident
Location of incident (address or nearest intersection)
Type of incident
Motor vehicle collision
Slip, trip, or fall
Workplace accident
Medical incident
Dog bite/animal attack
Defective product
Assault
Other
Please Specify:
Brief description of what happened
Who do you believe was at fault?
Another party
Me
Shared responsibility
Unsure
Were there any witnesses?
Yes
No
Areas injured
Please Specify:
Medical treatment received so far
Please Specify:
Are you still receiving treatment?
Yes
No
Health care providers seen (names or facilities)
Any pre-existing conditions affecting the same areas?
Yes
No
Do you have auto insurance?
Yes
No
Do you have health/medical insurance?
Yes
No
Have you already opened an insurance claim?
Yes
No
Were you employed at the time of the incident?
Yes
No
Did you miss work because of the incident?
Yes
No
Was any property (for example, a vehicle) damaged?
Yes
No
Have you spoken with any attorney about this incident?
Yes
No
May we contact you about your case?
Yes
No
Type your full name as your signature
Signature date
I understand this submission does not create an attorney-client relationship.
Yes
No
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Paper art illustration featuring a personal injury intake form and related legal elements for FormCreatorAI article.

When to use this form

Use this template when you need to screen and onboard new injury matters fast. Capture key facts after a car crash, slip and fall, workplace incident, or dog bite, even if the client is still at the clinic or calling from the scene. Paralegals and intake teams use it to confirm venue, parties, and urgent care needs, then flag cases for attorney review. It helps you assess liability, damages, and deadlines in one pass, so you can prioritize next steps. For general onboarding details and conflicts, pair it with the Client intake form. To track records requests and follow-ups, connect it to the Case management form.

Must Ask Personal Injury Intake Questions

  1. What happened, where, and when?

    This fixes the timeline and location, so you can assess jurisdiction, venue, and statute deadlines. Clear facts also reveal evidence sources like police reports, CCTV, or incident logs.

  2. What injuries and symptoms do you have now, and how severe are they?

    Severity and affected areas guide medical triage and support early damages estimates. If the client reports anxiety, sleep issues, or trauma symptoms, coordinate with the Psychology intake form for a fuller picture.

  3. What medical treatment have you received so far, and from which providers?

    Knowing facilities, dates, and provider names tells you which records and bills to request. It also shows causation and gaps in care that could hurt valuation.

  4. Do you have any pre-existing conditions or prior injuries to the same areas?

    This helps separate new harm from old issues and anticipates defense arguments. It informs strategy, disclosures, and whether you need specialist opinions.

  5. What insurance coverage applies (auto, health, or property), and have you opened any claims?

    Carrier and policy details enable faster communication with adjusters and potential medical payments coverage. Listing claim numbers and correspondence helps you track liens and payers from day one.

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