Tell Us How We Can Help You.  Call us: (816) 472-HOPE (4673), Toll-Free: 888-520-5581 or Click Here For E-MailWe strive to bring justice for those who have been hurt and those whose lives have been damaged by the wrongdoings of others.  Our goal is to have happy, healthy clients with restored lives.

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Personal Injury Intake Form

*Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Who was injured?

If "Other," please describe:

Injured person's name (if different from above):

Address:

City:

State:

Zip:

E-mail address:

Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

When did the injury occur?

Where did the injury occur?

Was this location the injured person's

If "Workplace," did the injury occur as a result of employment activities?
Yes   No 

If "Other," was this a road accident?
Yes   No 

If no, did the injury occur on another's property?
Yes   No 

If yes, who owns the property?

How did the injury happen?

What were the surrounding circumstances (weather, lighting, slipperiness, other)?

Were there witnesses to the injury?
Yes   No 

If yes, what are the witnesses names/contact information?

Were others involved or injured at the same time?
Yes   No 

If yes, what are their names/contact information?

Was there a police report?
Yes   No 

Did the injured person receive medical treatment?
Yes   No 

If yes, provide dates, locations, provider names, and details:

Is the injured person still receiving treatment?
Yes   No 

Was the injured person killed as a result of the accident?
Yes   No 

If yes, what was the date of his or her death?

Describe lifestyle changes experienced by the injured person and his or her family as a result of the accident:

Describe other losses resulting from the injury (lost wages, damaged property, other):

Where did you hear about this website?

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