---

name: pi-intake-form language: en description: >- Drafts a structured personal injury client intake form for initial consultations covering client identification, incident details, injury/treatment history, insurance, prior legal history, and authorizations. Supports conflict checking, case evaluation, and engagement setup. Use when onboarding a new PI client, creating intake questionnaires, or building pre-filing client records. Trigger keywords: personal injury intake, client onboarding, PI questionnaire, accident intake, injury claim intake. tags:

• checklist
• drafting
• litigation

---

Personal Injury Client Intake Form

Drafts a fillable intake form for prospective personal injury clients that supports conflict checking, statute-of-limitations tracking, case evaluation, and engagement setup.

Prerequisites

1. Jurisdiction — state of incident and client residence (determines SOL, comparative fault rules, damage caps, no-fault requirements).
2. Firm details — firm name, address, contact info, fee structure (contingency percentage, cost advancement policy).
3. Documents already provided — accident reports, medical records, photos, correspondence — to pre-populate fields and generate follow-up questions.

Output Structure

Generate a fillable intake form with the following sections in order. Calculate and flag the statute-of-limitations deadline prominently at the top based on jurisdiction and incident type.

1) Client Identification

Field	Notes
Full legal name	As on government ID
Former names / aliases	For conflict checking
Date of birth
SSN (last 4 only)	Include privacy notice
Residential address
Mailing address (if different)
Marital status / spouse name	Loss-of-consortium relevance
Dependents (names, ages)	Wrongful death relevance

2) Contact & Communication

Field	Notes
Primary phone	Mobile / landline
Secondary phone
Email (personal / work)
Preferred contact method	Phone / email / text / portal
Do NOT contact at	Confidentiality concerns
Text/email consent	Security limitation warning
Authorized recipients	Others permitted case info
Interpreter / accommodation	Language or accessibility needs

3) Incident Details

• Date of incident — flag SOL deadline (verify jurisdiction-specific period)
• Location — street address, city, county, state
• Type — motor vehicle, slip/fall, premises liability, product liability, medical malpractice, dog bite, workplace, other
• Narrative — client's own words, chronological
• Conditions — weather, road, environmental (if applicable)
• Police / incident report — report number, agency
• Witnesses — name, phone, relationship, observations
• Photos / video — scene, injuries, property damage

4) Parties Involved

For each opposing party and additional involved parties:

Field	Details
Full name
Role	At-fault driver, property owner, employer, manufacturer, etc.
Contact info / address
Insurance carrier & policy #	If known
Attorney (if represented)	Name, firm, contact
Employer	If commercial vehicle / on-the-job
Relationship to client	Stranger, employer, landlord, etc.

Ensure every named person/entity is captured for conflict-system intake.

5) Injuries & Medical Treatment

• Injuries sustained — body parts, diagnosis if known
• Ambulance transport — destination facility
• ER / urgent care — date, facility
• Treating physicians — name, specialty, facility, treatment dates
• Ongoing treatment — PT, scheduled surgery, pain management
• Pre-existing conditions — same body parts or related (critical for causation)
• Lost work days — dates, employer, wage rate
• Current symptom status — improving / stable / worsening
• Medical records authorization — HIPAA-compliant release attached

6) Insurance Information

Type	Carrier	Policy #	Limits (if known)
Client auto
Client health
UM/UIM coverage
MedPay / PIP
At-fault liability
Homeowner's / renter's
Umbrella

• Recorded statement given? — to whom, when (flag as red flag)
• Signed anything from opposing insurer? — flag immediately

Note: no-fault states require adjusted insurance sections [VERIFY jurisdiction].

7) Property Damage

• Vehicle year/make/model, current location
• Repair estimate or total loss determination
• Rental car status
• Personal property damaged

8) Prior Legal History

• Prior attorneys on this matter — name, firm, dates, reason ended
• Pending / prior litigation (past 10 years) — case, court, status
• Prior PI claims — critical for credibility and IME preparation
• Criminal history — may be discoverable
• Bankruptcy filings — affects claim ownership
• Family members with matters at firm — conflict check

9) Financial / Fee Discussion

• Employment status and occupation
• Income range (bracketed: <$25K / $25-50K / $50-100K / $100K+)
• Contingency fee explanation — plain-language description
• Cost advancement acknowledgment
• Lien awareness — Medicare, Medicaid, ERISA, workers' comp, child support

State that a separate written contingency fee agreement will follow if the firm accepts the matter. Do not include a fee agreement in the intake form.

10) Authorizations & Disclosures

Include with signature lines:

• No attorney-client relationship disclaimer — intake does not create representation
• Medical records authorization (HIPAA-compliant, separate signature)
• Employment records authorization
• Insurance records authorization
• Third-party communication consent
• Data privacy notice
• Text/email communication consent (with security warnings)
• Accuracy acknowledgment

Signature blocks: prospective client, intake attorney, date.

Guidelines

• Flag SOL deadline at top of completed form; verify jurisdiction-specific periods.
• Use plain language throughout — clients are often injured and stressed.
• Pre-populate from uploaded documents; generate specific follow-up questions for gaps.
• Capture all named persons/entities in conflict-check-compatible format.
• Note state-specific variations: no-fault insurance, pure vs. modified comparative fault, damage caps [VERIFY].
• Flag red flags early: prior recorded statements, signed releases, pre-existing conditions in same body part, approaching SOL.
• Formatting: minimum 11pt body, adequate white space, section headers, fillable fields.
• Use [VERIFY] for all jurisdiction-specific rules before finalizing.

Cross-references

• @demand-letter-personal-injury
• @medical-records-summary
• @contingency-fee-agreement
• @hipaa-authorization