Client Intake Form

CLIENT DISCOVERY INTAKE FORM INSTRUCTIONS:

This is the first step in your case, called discovery. We’ll use your answers to provide details about you and your accident to the insurance company. Please answer every question or write “N/A” if something doesn’t apply.

Your responses should be complete and truthful, just as if you were in court. Inaccurate or incomplete answers can hurt your case.

If you have questions about what to include or why certain information is needed, call us at (404) 526-9955. Because you’re filing an injury claim, the insurance company has a right to know about your background and medical history.

Client Discovery Intake Form

"*" indicates required fields

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BACKGROUND / PERSONAL INFORMATION

Name*

First Middle Last

Are you married?

Yes

Maiden Name*

Spouse's Name:*

Email*

Date of Birth:*

Social Security Number:*

City/State of Birth:*

Current Home Address*

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

Do you live with anyone else over the age of 18?*

Yes

Please provide the full name of all persons over the age of 18 who live with you:*

List all prior addresses last ten (10) years, and the approximate dates you lived at each address:

Who was your Cell Phone Provider/Company, on the date of the accident?*

(Example: MetroPCS)

Who was your Account Holder on the date of the accident?*

(Example: John Smith)

What was your Cell Phone # on the date of the accident?*

(Example: 404-555-5555)

Were you using your cell phone at the time of the accident for any reason (texting, making a call, streaming music through Bluetooth, etc.) The insurance company will order your cell phone records to verify?*

Yes

Please provide information on how you were using the phone at the time of the crash:*

(Example: I was streaming music to my radio, or I was making a hands-free phone call, or I was sending a text message)

Did you post or create ANY social media content (written posts, photos, stories, videos, etc.) about this accident on any social media site (including Facebook, Twitter, Instagram, Snapchat, TikTok, and YouTube)?

Did you post or create ANY social media content (written posts, photos, stories, videos, etc.) about this accident on any social media site (including Facebook, Twitter, Instagram, Snapchat, TikTok, and YouTube)?*

Yes

You must provide a screenshot of each post and all comments under the post. Failure to provide screenshots of all posts may result in a loss of your case:

You must provide a screenshot of each post and all comments under the post. Failure to provide screenshots of all posts may result in a loss of your case:*

Drop files here or

Max. file size: 1 GB.

Have you ever filed for bankruptcy?*

Yes

Please provide: the year you filed; (b) the city where you filed; the type of bankruptcy you filed and (d) if your bankruptcy was completed, is still ongoing, or if you dismissed the claim before it was finalized.*

Example: 2014, Chapter 7, Atlanta Bankruptcy Court, Discharged in 2015

Have you traveled outside of the State of Georgia since this accident for any reason (vacation, work, etc.)?

Yes

Please provide: The destination, the purpose of your trip, method of travel (driving, flying, cruise ship, etc.), and any activities you did on your trip: (Example: Cancun Mexico, Vacation, Flew from Atlanta, went SCUBA diving)

Destination*

Example: Cancun Mexico

The purpose of your trip*

Example: vacation, work, etc.

Method of travel (driving, flying, cruise ship, etc.)*

Example: (driving, flying, cruise ship, etc.)

Any activities you did on your trip*

(Example: Cancun Mexico, Vacation, Flew from Atlanta, went SCUBA diving)

Do you wear an Apple Watch, Fitbit, Garmin Watch or other fitness tracker on a regular basis?*

Yes

Please provide the type of fitness tracker you wear (the insurance company will ask to review the data to see if you have been active since the accident to argue against your pain and suffering claim)*

Do you belong to any church, fraternity/sorority, social club, union, lodge, committee or association?*

Yes

Please describe all below:*

Have you ever served in the United States Military?*

Yes

Please provide the branch, date(s) of service, and highest rank achieved:*

Do you have a valid driver’s license?*

Yes

Please provide a photograph of the FRONT of your driver’s license*

Drop files here or

Max. file size: 1 GB.

Please provide a photograph of the BACK of your driver’s license*

Drop files here or

Max. file size: 1 GB.

Please provide the full URLs to all of your social media profiles, such as Facebook, Instagram, TikTok, X/Twitter, LinkedIn, etc.

Example: https://www.instagram.com/yourusername

EDUCATION HISTORY

Did you attend high school?*

Yes

Provide the name of your school and the year(s) you attended:*

Did you attend college or technical school?*

Yes

Provide the name of your school and the year(s) you attended, and what your major was if you graduated:*

Did you attend graduate school?*

Yes

Provide the name of your school and the year(s) you attended, and what your major was if you graduated:*

Do you currently hold any specialized degrees, licenses, certifications, or other training?*

Yes

Please list your degrees, licenses, certifications, or training.*

CRIMINAL & DRIVING HISTORY

Have you ever been arrested for any reason (even if the case was later dismissed)? We are required to disclose all arrests to the insurance company or your case may be dismissed by the court.

Have you ever been arrested for any reason (even if the case was later dismissed)? We are required to disclose all arrests to the insurance company or your case may be dismissed by the court?*

Yes

Please provide the approximate year, the charge(s), the county, and the sentence for each and every arrest*

Approximate year

The charge(s)

The county

The sentence for arrest

[Example: 2020, Possession of Marijuana, Fulton County, 12 Months Probation]

Have you ever received any traffic tickets in the last 5 years?

Have you ever received any traffic tickets in the last 5 years?*

Yes

Please provide the traffic offense, the court, the approximate date of the offense, and the sentence.

List*

[Example: Speeding (25 MPH over speed limit), City of Atlanta Traffic Court, 2023, Paid Fine]

MEDICAL HISTORY

Did you consume any alcohol or drugs in the 24 hour period before this accident?*

Yes

Please list what substance(s) you consumed and the amount(s):

List*

What substance(s) you consumed?

The amount(s)

Are you required to wear glasses or contacts when you drive?*

Yes

Were you wearing them on the date of this accident?*

Were you taking any prescription medication on the date of this crash?*

Yes

Please provide the name(s) of your prescription medication(s) and the doctor who prescribed it for you.*

(Example: Lipitor – Prescribed by Dr. John Smith)

Have you ever had surgery for ANY reason before or after this accident?*

Yes

Please provide: (1) The type of surgery; (2) The doctor or medical facility who performed the surgery; and (3) The approximate date of the surgery.

The type of surgery

The doctor or medical facility who performed the surgery

The approximate date of the surgery

(Example: C-Section, Appendix Removed, Piedmont Atlanta Hospital, 2015)

Please list ALL doctors or medical practices you have seen in the last ten (10) years (OTHER than those you treated with for this accident, we have those names already) and the reason you see that doctor. Please include your primary doctor, dentist, family doctors, therapists, OBGYN, and other specialists.

Please list ALL doctors or medical practices you have seen in the last ten (10) years (OTHER than those you treated with for this accident, we have those names already) and the reason you see that doctor. Please include your primary doctor, dentist, family doctors, therapists, OBGYN, and other specialists.

(Example: Dr. John Smith, Primary Care; Dr. Robert Jones, Cardiologist)

Please list the name and address of all pharmacies you have used in the last five (5) years. The insurance company will verify all Rx drugs you received in the timeframe around this accident

Please list the name and address of all pharmacies you have used in the last five (5) years. The insurance company will verify all Rx drugs you received in the timeframe around this accident

Example: (CVS on Cheshire Bridge Road; Kroger on North Decatur Road)

If you had health insurance, Obamacare, Medicare, Medicaid, Peach State Health Plan, CHAMPUS, Tricare, or any other health insurance coverage on the date of this accident – Please upload a FRONT AND BACK photo of your insurance card. FAILURE TO PROVIDE THIS INFORMATION WILL RESULT IN A LONG DELAY IN SETTLING YOUR CASE AND/OR THE CANCELLATION OF YOUR INSURANCE BY YOUR PROVIDER.

Drop files here or

Max. file size: 1 GB.

Has your health insurance company contacted you about this accident?*

Yes

Please provide the phone number and case number for their claim (they may have sent you some paperwork to fill out, you may call our office if you received this paperwork to discuss)

Phone Number for Health Insurance Rep

Claim Number from Health Insurance Rep*

Did you have ANY prior/pre-existing injury, disease, or chronic medical condition before the date of this accident?

Did you have ANY prior/pre-existing injury, disease, or chronic medical condition before the date of this accident?*

Yes

Please describe what the injury was, how long you have had the injury, how you received it, and which doctor(s) you treated with for the injury. Even if the injury, surgery or disease has NOTHING to do with this accident, you MUST disclose it. Failure to provide ALL medical history may result in your case being dismissed.

Please describe what the injury was, how long you have had the injury, how you received it, and which doctor(s) you treated with for the injury. Even if the injury, surgery or disease has NOTHING to do with this accident, you MUST disclose it. Failure to provide ALL medical history may result in your case being dismissed.*

Example: Diabetes Type 2 – Treat at Piedmont; Prior Back Injury from 2021 Car Accident – Treated with OrthoAtlanta, etc

Have you ever been diagnosed with Lou Gehrig’s Disease?*

Yes

Have you ever been diagnosed with End Stage Renal Disease?*

Yes

Have you ever received Medicare Benefits or Social Security Disability Benefits?*

Yes

Untitled*

Example: What benefit received, when, why, how much etc.

Are you currently receiving medicare benefits or social security disability benefits?*

Yes

Untitled*

Example: What benefits recevied, when, why, how much etc.

Do you receive a Federal Railroad Pension?*

Yes

EMPLOYMENT HISTORY

Are you currently employed?*

Yes

Please provide the name and address of your employer, your job title, your pay rate or salary, and the year(s) of employment.*

Example: Home Depot on Piedmont Avenue, Cashier, $15.00/hour, 2015 – Present Day

On the date and time of this crash were you on the clock for an employer?*

Yes

Please provide the name of the employer and describe what you were doing for them*

Example: Driving to pick up lunch for my boss at Home Depot

Please list all employers you have worked for in the last five (5) years, starting with the most recent. Please include the company name, location, supervisor name, rate of pay, job title, and date(s) of employment.*

Example: Target (Buckhead), Supervisor John Smith, $15.00/hour, Cashier, 2020-2021

Do you wish to claim lost wages and provide this information to our office? If you are claiming lost wages you will need to provide your STATE and FEDERAL tax returns for the last five (5) years to prove your income, along with a paystub proving your wages.*

Yes

Did you miss any shifts or hours at work as a result of this accident (including time missed due to injury or for medical appointments)?*

Yes

Please provide the name of the employer, the number of hours/days you missed, your rate of pay at the time, and your job duties.*

Example: I missed 25 hours at my job as a cashier for Home Depot due to medical appointments, $15.00 per hour.

Have you applied for a job in the year before or year after this crash?*

Yes

Please provide a listing of all places you applied and the dates of your applications

Example: Applied at Target in 2022, Applied at Chick-Fil-A in 2022

ACCIDENT/INSURANCE CLAIMS/LAWSUIT HISTORY

Have you ever been divorced before?*

Yes

Provide the county/state where your divorce case was filed, and the approximate year:*

Have you ever been sued by someone else before?*

Yes

Please provide a brief description of the lawsuit*

Example: Sued for bounced check 2015, Fulton County, GA; sued for eviction in 2020, DeKalb County, GA.

The lawyer for the insurance company will ask about ALL prior claims for injury. Failure to disclose ALL prior injury claims will result in your case being lost. If you have any questions about how to answer the following questions, please call our office at 404-526-9955 to discuss.

Have you ever filed a Workers Compensation claim for an injury on the job?*

Yes

Please provide the name of the employer, the type of injury, the name(s) of all doctors you saw for the injury, the year of the injury, and the settlement information below.

Name of the employer*

Example: Home Depot

The type of injury*

Example: back injury from lifting boxes

The name(s) of all doctors you saw for the injury*

Example: went to Concentra Urgent Care

The year of the injury*

Example: 2015

The settlement information below*

Example: settled for $2500.00

Have you ever filed a claim against a store or business for an injury that occurred on their property (slip-and-fall claim, etc.)?*

Yes

Please provide the name of the business, the type of injury, the year of the injury, and any settlement information below.

Name of the business*

Example: Slip and Fall – Publix Grocery Store

The type of injury*

Example: Injured my Right Knee

The year of the injury*

Example: 2015

Any settlement information*

Example: Settled for $2500.00

Have you ever been injured in a car accident BEFORE the current accident (as a driver, passenger, or pedestrian)? It doesn’t matter who was at fault for the crash?*

Yes

Please provide the approximate year and location, the type of accident, all parts of your body that were injured, the types/names of doctors that you saw, and any settlement information for ALL PRIOR ACCIDENTS below.

The approximate year and location*

Example: 2020 – Rear end collision in Atlanta, GA

The type of accident*

All parts of your body that were injured*

Example: Injured my neck and back

The types/names of doctors that you saw*

Example: I went to OrthoAtlanta and Piedmont Hospital

Any settlement information for ALL PRIOR ACCIDENTS*

Example: Case settled for $2500.00

Have you ever been injured in a car accident AFTER the current accident (as a driver, passenger, or pedestrian)? It doesn’t matter who was at fault for the crash?*

Yes

The approximate year and location*

Example: 2023 – head on collision in Atlanta, GA

The type of accident*

All parts of your body that were injured*

Example: broken arm

The types/names of doctors that you saw*

Example: I went to Piedmont Hospital

Any settlement information for ALL SUBSEQUENT ACCIDENTS*

Example: Case is still open

INFORMATION ABOUT THIS ACCIDENT

On the date and time of this accident, where were you coming from, and what was your intended destination*

(Example: Leaving my job at Home Depot, going back home)

Describe in your own words how the crash happened (we already have the police report if you filed one but we are still required to explain the accident in your own words to the insurance attorney):*

Did you have any passengers in the car?*

Yes

Please list all passengers and describe where each one was seated in your vehicle.*

Example: John Smith, Front Passenger Seat

Did you speak to any other witnesses at the scene of the crash?*

Yes

Please provide their name and phone number below:*

Example: John Smith (000-000-0000)

Did you speak with the at-fault driver or their passenger(s) at the scene of the crash before police arrived?*

Yes

Please describe your conversation:*

Did you own the car involved in the crash?*

Yes

Please provide the owner’s name*

If you did NOT own the car involved in this crash, did you have your own vehicle with insurance on the day of the crash?*

Yes

Please provide a photo of your insurance card for that vehicle below:

Drop files here or

Max. file size: 1 GB.

Describe what part(s) of your car were damaged:*

Do you have any photos or videos of the crash scene?*

Yes

Please provide them below*

Drop files here or

Max. file size: 1 GB.

Was your car repaired?*

Yes

How much did the repair cost?*

Did you damage any personal property (besides your car) in this accident (such as a cell phone or tablet)?*

Yes

Provide a brief description of the item(s) and their replacement cost*

Example: [Broken iPad, $750 replacement cost, photo of iPad is attached.

Upload photo(s) of the damaged item(s)*

Drop files here or

Max. file size: 1 GB.

Did you call the police/911 after the accident or did someone else say they were calling?*

Which police department responded to the crash?*

Did you tell the officer or 911 that you were injured or ask for an ambulance? The insurance company attorney will order the officer’s body cam video to verify*

Yes

Did you get a citation or were you arrested for anything when the police came to the scene?*

Yes

Please describe the reason you were cited or arrested:*

Please describe in your own words each and every injury you received as a result of this accident.*

Example: Left shoulder in pain, right knee injured, lower back sore, broken wrist, etc.

Are you still treating with any medical doctor or chiropractor for injuries related to this accident?*

Yes

Please provide the name of the clinic/doctor and the reason you see them.*

Example: Treating with Dr. John Smith at Atlanta Pain Management for back pain

Have you made a full recovery from this accident or are you still in pain? If you are still in pain, do you have plans to seek further treatment?*

Full Recovery

Still in pain

Please describe what part(s) of your body are still in pain and what doctor(s) you plan to see.*

Example (Neck still in pain, plan to see an orthopedist next month):

Do you keep a journal, diary, or blog where you discuss your pain and suffering from this accident?*

Yes

You must provide copies of all entries/posts related to this accident and your pain and suffering:*

Drop files here or

Max. file size: 1 GB.

Are there any witnesses who can testify about the change in your quality of life due to these injuries from this accident?*

Yes

Please provide their full name, address, phone, and email:*

Full Name

Address

Phone

If you are married, have you experienced a decrease in the number of times per week you engage in sexual intercourse with your spouse?*

Yes

Please describe the average number of times per week you were sexually active before this accident, and describe how many times per week you are sexually active after the accident. You may leave this section blank if you do not want to include this claim in your lawsuit.

Have you taken out any pre-litigation funding or a cash advance from any company like Oasis, Cash Now, JG Wentworth, etc.?*

Yes

Please provide the name of the company and the approximate amount borrowed:

Name of the company*

Approximate amount borrowed*

Are there any activities you are unable to perform as a result of your injuries from this accident?*

Yes

Describe them*

Examples: Cancelled gym membership, trouble sleeping, trouble sitting for long periods of time, difficulty with romantic/physical relationships, trouble with household chores/lawncare, etc.

Did you have to hire anyone to cook, clean, mow your lawn, etc. as a result of your injuries?*

Yes

Please provide their name, contact information, and the service(s) they performed:*

Name

Contact information

Service(s) they performed

Signature*

Print full name*

I swear under penalty of perjury that the information I provided in this Discovery Form is true, correct, and accurate to the best of my knowledge. I understand and acknowledge that failure to provide my attorneys with full, complete and truthful information may result in my case being lost.

Date*

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Client Intake Form

CLIENT DISCOVERY INTAKE FORM INSTRUCTIONS:

Client Discovery Intake Form

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