POTENTIAL CLIENT INTERVIEW FORM

POTENTIAL CLIENT INTERVIEW FORM

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We should be prepared for interviews with potential new clients whether electronically or by written form. Getting all of the necessary information is important in evaluating whether to take the care or not. In addition, a thorough interview at the time of initial conference with a potential new client reflects the lawyers experience and knowledge. What follows is a simple, basic outline of subject matter to consider in drafting your own client interview form.

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INITIAL CONTACT INFORMATION

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NATURE OF CASE:

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Type of Case: ( ) Malpractice ( ) Auto ( ) Product ( ) Death ( ) Other_____________

Date of Injury/Death:_________________ Place of Injury/Death:________________           

Nature of Injuries:___________________________             _______________________

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THE INJURED OR DECEASED PERSON

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First Name_________ Middle I_______ Last Name__________________________

Address                                          City_________________________ State_______ Zip__________Home Phone (____)_____________Work Phone (____)___________

E-Mail_____________________Date of Birth__________________

Employer/Occupation________________________________________

Spouses Name________________   Spouses Date of Birth:___________

Spouses Occupation__________________________________________________    

SOCIAL SECURITY NO.______________BIRTH DATE______________              

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INJURY TO A CHILD

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Mothers Name________________________________

Fathers Name________________________________

Brothers & sisters: ____________________________

                                                                                                                                               

POTENTIAL DEFENDANT INFORMATION

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(1) DEFENDANT                                                              CITY _________________                                            

Insurance Co.:                                               Insurance Adjuster___________                         

(2) DEFENDANT                                       +                    CITY__________________                                             

Insurance Co.:                                                 Insurance Adjuster___________                    

(3) DEFENDANT                                                            CITY                      

Insurance Co.:                                                             Insurance Adjuster __________                

(4)  (OTHERS: Use reverse side)

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CLIENT INSURANCE

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(1)Auto___________________________________________________________
(2)Medical Insurance                                                                                                            
(3)L&I Claim?_____________________________________________________
(4)Other__________________________                                                                                                                    

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FACTS:  Explanation of how injury occurred (draw diagram on following page):__________  

_________________________________________________________________________________________________________________________

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NEGLIGENCE CLAIMED

__________________________________________________________________________________________________________________________________________________                                                                                                                                                    

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NATURE OF INJURIES

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Description of injuries________________________________                                                                                                                                                                                                                                                                                                           Description of Present Condition__________________________________________________                                                                                                                                                                                                                                                              

Prognosis_____________________________________________________________                                                                                                                                                                                                                                                                                    Recommended Treatment or Surgeries_____________________________________________   

                                                                                                                                                                                              

OUT OF POCKET EXPENSES

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$                                                   Total Medical

$                                                   Total Past Wage Loss

$                                                   Total Property Damage

$                                                   TOTAL OF ALL LOSSES

$                                                   Estimated Future Wage Loss

$                                                    Estimated Future Medical

$                                                    Estimated Other

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Information Regarding Out-of-Pocket Expenses_____________________________________

___________________________________________________________________________

PREEXISTING MEDICAL CONDITIONS OR INJURIES

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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TREATING DOCTORS

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(1) Name                                                   City                           Specialty___________            

(2) Name                                                     City                            Specialty___________                    

(3) Name                                                      City                            Specialty___________                    

(4) Name                                                     City                           Specialty___________                    

(5) Name                                                     City                            Specialty___________                    

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HOSPITALS

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(1) Name                                                     City                            Dates _____________                           Reason_________________________________                                                                                                                                  

(2) Name                                                     City                            Dates_____________                            Reason________________________________                                                                                                                                   

(3) Name                                                     City                            Dates_____________                           Reason__________________________________________________________________                                                                                

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KEY WITNESSES

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Doctors/Nurses____________________________________________________________                                                       

Eye Witnesses_____________________________________________________________                      

Other Witnesses___________________________________________________________

SETTLEMENT OFFERS

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Offer Received $                                         How Given (writing, oral, etc.)                  

ADVICE GIVEN CLIENT

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( ) Statute of Limitations

( ) Attorney fees

( ) Liability evaluation_____________________________________________________

( ) Damage evaluation_____________________________________________________

( ) Need for Probate and/or Guardianship

( ) Need for Filing Tort Claim

( ) Other_________________________________________________________________

                                                                                                                                                                                                                                                                                                                  

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STATUS

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COPY MADE OF DRIVERS LICENSE
RETAINER SIGNED

EVALUATION

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CLEAR LIABILITY
ABOVE AVERAGE LIABILITY
AVERAGE LIABILITY
BELOW AVERAGE LIABILITY

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MAJOR DAMAGES
ABOVE AVERAGE DAMAGES
AVERAGE DAMAGES
BELOW AVERAGE DAMAGES

Comment______________________________________________________________________________

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Comparative negligence evaluation______________________________________________                                                                                              

Recommendation re accepting case______________________________________________                                                                

Potential Settlement Value Range $______________________________________________                                                                                               

Potential Jury Value Range $___________________________________________________

                                                                                                        

SOCIAL MEDIA

List of all social media accounts + passwords_______________________________________________________________________________

Blogs or internet publications______________________________________________________________________________________________

CLIENT IMPRESSION

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( ) Excellent ( ) Above Average ( ) Average ( ) Below Average ( ) Poor

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General Impression of Client ____________________________________________________

                                                                                                         

PLAN FOR FILE   The plan for this file____________________________________________

____________________________________________________________________________.

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