POTENTIAL CLIENT INTERVIEW FORM
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.
INITIAL CONTACT INFORMATION
NATURE OF CASE:
Type of Case: ( ) Malpractice ( ) Auto ( ) Product ( ) Death ( ) Other_____________
Date of Injury/Death:_________________ Place of Injury/Death:________________
Nature of Injuries:___________________________ _______________________
THE INJURED OR DECEASED PERSON
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______________
INJURY TO A CHILD
Mothers Name________________________________
Fathers Name________________________________
Brothers & sisters: ____________________________
POTENTIAL DEFENDANT INFORMATION
(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)
CLIENT INSURANCE
FACTS: Explanation of how injury occurred (draw diagram on following page):__________
_________________________________________________________________________________________________________________________
NEGLIGENCE CLAIMED
__________________________________________________________________________________________________________________________________________________
NATURE OF INJURIES
Description of injuries________________________________ Description of Present Condition__________________________________________________
Prognosis_____________________________________________________________ Recommended Treatment or Surgeries_____________________________________________
OUT OF POCKET EXPENSES
$ Total Medical
$ Total Past Wage Loss
$ Total Property Damage
$ TOTAL OF ALL LOSSES
$ Estimated Future Wage Loss
$ Estimated Future Medical
$ Estimated Other
Information Regarding Out-of-Pocket Expenses_____________________________________
___________________________________________________________________________
PREEXISTING MEDICAL CONDITIONS OR INJURIES
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
TREATING DOCTORS
(1) Name City Specialty___________
(2) Name City Specialty___________
(3) Name City Specialty___________
(4) Name City Specialty___________
(5) Name City Specialty___________
HOSPITALS
(1) Name City Dates _____________ Reason_________________________________
(2) Name City Dates_____________ Reason________________________________
(3) Name City Dates_____________ Reason__________________________________________________________________
KEY WITNESSES
Doctors/Nurses____________________________________________________________
Eye Witnesses_____________________________________________________________
Other Witnesses___________________________________________________________
SETTLEMENT OFFERS
Offer Received $ How Given (writing, oral, etc.)
ADVICE GIVEN CLIENT
( ) Statute of Limitations
( ) Attorney fees
( ) Liability evaluation_____________________________________________________
( ) Damage evaluation_____________________________________________________
( ) Need for Probate and/or Guardianship
( ) Need for Filing Tort Claim
( ) Other_________________________________________________________________
STATUS
EVALUATION
|
CLEAR LIABILITY
ABOVE AVERAGE LIABILITY
AVERAGE LIABILITY
BELOW AVERAGE LIABILITY
|
MAJOR DAMAGES
ABOVE AVERAGE DAMAGES
AVERAGE DAMAGES
BELOW AVERAGE DAMAGES
Comment______________________________________________________________________________ |
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
( ) Excellent ( ) Above Average ( ) Average ( ) Below Average ( ) Poor
General Impression of Client ____________________________________________________
PLAN FOR FILE The plan for this file____________________________________________
____________________________________________________________________________