Law Office of Clayton C. Ikei
Potential Client Screening Questionnaire
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PERSONAL INJURY CASES
Directions
The form is a list of questions which our firm uses to screen potential clients. The screening process helps us to determine if you have the type of case which we handle. It also helps us determine if we have a potential conflict of interest in handling your case. If we do, we cannot ethically represent you. Please understand that simply submitting a questionnaire does not, as a matter of course, mean that the firm does represent you or will be able to represent you. The purpose of this questionnaire is only to help us to determine if we are able to do so.
Our firm processes intakes in several ways: via telephone, via mail and via e-mail. If you wish to submit your questionnaire by telephone, please have this form with you when you call it will help you to answer questions as we go through them. Alternatively, you can print out the form and mail it to us at the above address or fax it to us at the above number. If you wish to contact our office via e-mail, please use the form as a guideline for the information that you should submit to us.
Our firm keeps information submitted to us by potential clients confidential. You should use your own judgment about how to submit that information to us. If you have confidential or sensitive information you may prefer to contact us by telephone or by facsimile. If you chose to submit information via e-mail, we are not responsible if the information is intercepted while in transit over the Internet.
TIPS Some things to keep in mind as you fill in the form:
Please be as brief as possible, but also be specific. You do not need to try to win your case, but do give us enough information to understand it thoroughly.
Please include dates as much as possible ... if you can only remember the month and the year, that is better than leaving items without any date.
If you do not understand something, please contact us and we will attempt to explain it to you.
We ask your race and age and gender because that information can affect the type of claim you can make. When you refer to other people, please include their race, age and gender if you know them if you claim you are being harassed because of your race, it helps us to know if the person doing it is of a different race than you.
INTAKE QUESTIONNAIRE
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Name:
_____________________________________________________________________
Address:___________________________________________________________________
Home phone:__________
Pager/Cell phone:____________
Workphone:______________
Okay to call you at work? ( )YES ( ) NO
E-mail address: ___________________________________________________________
Please give us contract information about a person who will alwaysknow how to contact you. Name: ____________________________________
Relationship:_________________
Address: __________________________________________________________________
Home phone:__________
Pager/Cell phone:____________
Workphone:______________
Okay to call at work? ( )YES ( ) NO
E-mail address: __________________________________________________________
Accident Date: _____________
Location:____________________________________
Time of Day: _______________
Weather/Lighting: ___________________________
Traffic Conditions: ______________________________________________________
YOUR CAR:
Occupants: ________________________________________________________________
Your relationship to those occupants: _____________________________________
Describe your car: ________________________________________________________
How did the accident occur? _______________________________________________
___________________________________________________________________________
___________________________________________________________________________
(Please continue on back if necessary)
OTHER CAR
Accident involved: ( )Pedestrian ( ) Bicycle ( )Automobile( )Other
Please describe "other": __________________________________________________
Name of other party: ______________________________________________________
Other occupants of his/her vehicle: _______________________________________
Name of insurance carrier: ________________________________________________
WITNESSES: (1) Name: ________________________________________________________________
Address:___________________________________________________________________
Home phone:__________
Pager/Cell phone:____________
Workphone:______________
Okay to call you at work? ( )YES ( ) NO
(2) Name: ________________________________________________________________
Address:___________________________________________________________________
Home phone:__________
Pager/Cell phone:____________
Workphone:______________
Okay to call you at work? ( )YES ( ) NO
(3) Name: ________________________________________________________________
Address:___________________________________________________________________
Home phone:__________
Pager/Cell phone:____________
Workphone:______________
Okay to call you at work? ( )YES ( ) NO
INJURIES Were you injured? ________________________________________________________
Nature of injuries:_______________________________________________________
Did you seek medical treatment? __________________________________________
From whom? _______________________________________________________________
Name or description of other injured party:_______________________________
What injuries did they claim? ____________________________________________
What injuries did you observe? ___________________________________________
Treated by ambulance or paramedics?_______________________________________
Did anyone admit liability? ______________________________________________
What did that person say?_________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________