Intake

Wetherington Law Firm Intake

Please answer each question as fully and accurately as you can. Success in this case depends on mutual confidence and complete cooperation between you (as the client) and the attorney. It is imperative that your attorney know as much as possible about your claims. Feel free to set a phone appointment with the paralegal assigned to your case for assistance filling out this form. Your paralegal is happy to assist you. We anticipate it will take about thirty minutes to complete the form. If you do not have complete information, please add what you can and submit the form. You can add additional information later.

Is another person writing the answers to this questionnaire on your behalf? If so, please identify the helper.

How were you referred to the Wetherington Law Firm?

Basic Information

Legal Name

Prefix First Middle Last

Address

Street Address City State ZIP Code

Have you lived at a different address in the last five years?

Please list each address you have lived at during the previous five years:

Have you lived in a different state AFTER the incident?

Please list the states you have lived in since the wreck.

Phone

Date of Birth

Driver's License Number:

Social Security Number:

Current Marital Status

Your Spouse's Name:

First Last

Your Spouse's Date of Birth

Your Spouse's Email Address

Your Spouse's Phone Number

When were you married?

Have you divorced a prior spouse?

Yes

Please provide the names and dates of your prior marriage(s):

Do you have any children?

Yes

Please list the names and ages of each of your children

Who else lived in your residence(s) on the date of the accident? (Please check all that apply.)

Legal Spouse

Partner, not legally married

Adult Children

Sibling(s)

Parent(s)

Grandparent(s)

Roommate

Please identify which social media platforms you use and provide the handle or user name for your accounts.

If possible, provide a link to your account.

Have you ever served in the military?

Yes

Please provide the branch you served in, year of entry, year of discharge, highest rank, and discharge status.

Who was injured in this incident?

Select all that apply.

I was injured

My spouse was injured

My minor child was injured

No one was injured

How many of your children were injured?

One

Two

Three

Four

Five+

First injured child's name

First Last

First injured child's date of birth

Second injured child's name

First Last

Second injured child's date of birth

Third injured child's name

First Last

Third injured child's date of birth

Fourth injured child's name

First Last

Fourth injured child's date of birth

Fifth injured child's name

First Last

Fifth injured child's date of birth

The Vehicle You Were Riding In

Where were you seated in the vehicle?

Driver

Front Seat Passenger

Rear Seat Passnger

Not In a Vehicle

Where was your spouse seated in the vehicle?

Driver

Front Seat Passenger

Rear Seat Passnger

Not In a Vehicle

Where was your child seated in the vehicle?

Driver

Front Seat Passenger

Rear Seat Passnger

Not In a Vehicle

Were there other people in your vehicle who were NOT injured?

If yes, please identify the other people in the vehicle.

Did you or your spouse own the vehicle you were traveling in on the date of the wreck?

Yes

Who owned the vehicle you were riding in?

Are you aware of a CLAIM being filed with the company that insured the vehicle YOU WERE RIDING IN at the time of the wreck prior to our involvement?

Yes

If you know, which insurance company insured the vehicle THAT YOU WERE RIDING IN at the time of the wreck?

If you know, please provide the policy number, claim number, and/or adjuster name for the insurance company of the car you were driving in.

Any information you have will be helpful.

Your Automobile Insurance

Who do you have auto insurance with?

What is your insurance policy number?

Are you aware of a CLAIM being filed with your insurance company for the wreck?

Yes

If you know, please provide the claim number and/or adjuster name for the claim setup with your insurance company.

Any information you have will be helpful.

Please identify all family members that lived at your residence(s) who had THEIR OWN automobile insurance at the time of the wreck: (Please provide the name of the insurer and policy number, if known.)

Please only list people who lived with you or that you lived with around the time of the wreck.

Was the vehicle you were riding in the only vehicle involved in the wreck?

Select no if another vehicle caused the wreck.

Yes

In total, how many vehicles were involved in the wreck.

If you are uncertain if a vehicle was involved, please count that vehicle.

Wrongdoers Insurance

Do you recall speaking with the Wrongdoer?

Yes

Did the wrongdoer say anything that could be helpful to your case?

If you know, who did the wrongdoer have insurance with?

If you know, please provide the policy number, claim number and/or adjuster name for the claim setup with your insurance company.

Any information you have will be helpful.

Health Insurance

Are you a recipient of Medicare?

Yes

What is your Medicare number?

Are you a recipient of Medicaid?

Yes

What is your Medicaid number?

Is your spouse a recipient of Medicare?

Yes

What is your spouse's Medicare number?

Is your spouse a recipient of Medicaid?

Yes

What is your spouse's Medicaid number?

Do you have health insurance other than Medicare or Medicaid?

Yes

Who do you have health insurance with?

Please provide the ID and/or group number of any health insurer you were covered under at the time of the accident.

Is your health insurance provided through your employer or your spouse’s employer?

Yes, my employer

Yes, my spouse's employer

Yes, my parent's employer

What is the name of the company that provides your health insurance?

Does your spouse have health insurance other than Medicare or Medicaid?

Yes

Who does your spouse have health insurance with?

Please provide the ID and/or group number of any health insurer your spouse was covered under at the time of the accident.

Is your spouse's health insurance provided through your employer or your spouse’s employer?

Yes, my employer

Yes, my spouse's employer

Yes, my parent's employer

What is the name of the company that provides your spouse's health insurance?

Do you currently receive Social Security Disability Benefits?

Yes

What is the reason you are receiving SSD?

Does your spouse currently receive Social Security Benefits?

Yes

What is the reason your spouse is receiving SSD?

The Incident

Please provide the date of the incident.

In your own words, describe where the incident happened.

In your own words, describe what happened in the incident.

In your own words, who do you believe is responsible for the incident and why?

Have you given a statement to any insurance company regarding this incident?

Yes

Identify the circumstances and name of each insurance company that interviewed and/or obtained a statement from you.

Prior to the incident, had you been in the same area at some point before?

Examples: traveling down the same aisle at a grocery store before falling, using the same elevator, going to the same park.

Yes

Please describe how recently you had been to the same area and the circumstances of your visit.

Prior to the incident, had your spouse been in the same area at some point before?

Examples: traveling down the same aisle at a grocery store before falling, using the same elevator, going to the same park.

Yes

Please describe how recently you had been to the same area and the circumstances of your spouse's visit.

Prior to the incident, had your child been in the same area at some point before?

Examples: traveling down the same aisle at a grocery store before falling, using the same elevator, going to the same park.

Yes

Please describe how recently you had been to the same area and the circumstances of your child's visit.

Prior to the incident, did you take any prescription drugs?

Yes

What prescription drugs did you take prior to the incident?

Prior to the incident, did you ingest any alcohol or illegal drugs?

I prefer not to answer

Are you aware of any witnesses to the incident?

Yes

Describe any witnesses you are aware of and provide their contact information if you have it.

Do you have any photos from the scene of the incident?

Yes

Do you have any photos of injuries caused by the incident?

Yes

Do you have any photos of damage to the vehicles involved?

Yes

In the past ten years, have you been involved in any other wrecks?

Yes

Please describe any PRIOR accidents in which you were involved. For each accident, please include the DATE of the accident, the LOCATION, a description of a your INJURIES, if any, whether you received TREATMENT for injuries, and whether or not an insurance CLAIM was filed.

In the past ten years, has your spouse been involved in any other wrecks?

Yes

Please describe any PRIOR accidents in which your spouse was involved. For each accident, please include the DATE of the accident, the LOCATION, a description of any INJURIES, if any, whether your spouse received TREATMENT for injuries, and whether or not an insurance CLAIM was filed.

AFTER this incident, have you been involved in any other incidents where you have been injured or an insurance claim may have been filed?

Yes

Please describe any accidents in which you have been involved AFTER this incident. For each accident, please include the DATE of the accident, the LOCATION, a description of a your INJURIES, if any, whether you received TREATMENT for injuries, and whether or not an insurance CLAIM was filed.

AFTER this incident, has your spouse been involved in any other incidents where they have been injured or an insurance claim may have been filed?

Yes

Please describe any accidents in which your spouse has been involved AFTER this incident. For each accident, please include the DATE of the accident, the LOCATION, a description of any INJURIES, whether your spouse received TREATMENT for injuries, and whether or not an insurance CLAIM was filed.

Damages

Please identify each part of your body that was injured.

I know its weird to use a checkbox, but you would be shocked how many times people forget what parts of their body have been injured.

Please identify each part of your spouse's body that was injured.

I know its weird to use a checkbox, but you would be shocked how many times people forget what parts of their body have been injured.

Please identify each part of your child's body that was injured.

I know its weird to use a checkbox, but you would be shocked how many times people forget what parts of their body have been injured.

In your own words, describe your injuries:

In your own words, describe your SPOUSE'S injuries:

In your own words, describe your CHILD'S injuries:

Had you ever had a previous injury to the same specific part(s) of your body?

Yes

Please describe the circumstances of your prior injury:

If you know, has your spouse ever had a previous injury to the same specific part(s) of your body?

Yes

Please describe the circumstances of your spouse's prior injury:

If you know, has your child ever had a previous injury to the same specific part(s) of your body?

Yes

Please describe the circumstances of your child's prior injury:

Pain and suffering includes mental suffering. Anxiety, shock, and worry are examples of what might be included under mental pain and suffering. Please describe any mental suffering related to your life or activities that has contributed to your injuries.

This specifically includes anything that you were able to do before the incident that you are not able to do now.

Have you visited a therapist or otherwise received mental health treatment related to the incident?

Yes

Please identify the treatment you received and the name of the provider or facility.

Pain and suffering includes mental suffering. Anxiety, shock, and worry are examples of what might be included under mental pain and suffering. Please describe any mental suffering related to your spouse's life or activities that has contributed to their injuries.

This specifically includes anything that they were able to do before the incident that they are not able to do now.

Has your spouse visited a therapist or otherwise received mental health treatment related to the incident?

Yes

Please identify the treatment your spouse received and the name of the provider or facility.

Pain and suffering includes mental suffering. Anxiety, shock, and worry are examples of what might be included under mental pain and suffering. Please describe any mental suffering related to your child's life or activities that has contributed to their injuries.

This specifically includes anything that they were able to do before the incident that they are not able to do now.

Has your child visited a therapist or otherwise received mental health treatment related to the incident?

Yes

Please identify the treatment your child received and the name of the provider or facility.

Medical Treatment

Immediately following the incident, were you transported to a hospital or healthcare facility by ambulance or Emergency Medical Services (EMS)?

Yes

Immediately following the incident, was your spouse transported to a hospital or healthcare facility by ambulance or Emergency Medical Services (EMS)?

Yes

Immediately following the incident, was your child transported to a hospital or healthcare facility by ambulance or Emergency Medical Services (EMS)?

Yes

Please provide the name of the ambulance or EMS provider if you know it.

Please provide the name of the hospital you were taken to if you know it.

Please provide the name of the hospital your spouse wase taken to if you know it.

Please provide the name of the hospital your child was taken to if you know it.

If you were not transported by ambulance, but sought treatment at a hospital emergency room or health care facility immediately after the accident, please provide the name of the facility, and how you got there (e.g., you drove yourself, a family or friend drove you).

If your spouse was not transported by ambulance, but sought treatment at a hospital emergency room or health care facility immediately after the accident, please provide the name of the facility, and how you got there (e.g., you drove yourself, a family or friend drove you).

If your child was not transported by ambulance, but sought treatment at a hospital emergency room or health care facility immediately after the accident, please provide the name of the facility, and how you got there (e.g., you drove yourself, a family or friend drove you).

What is the date you were first treated for your injuries?

What is the date your spouse was first treated for your injuries?

What is the date your child was first treated for your injuries?

Other than the hospital, please list the name of each facility and/or professional you have treated with.

If you don't know the name of a provider or facility, please give us a best guess or tell us you don't remember and we will try to find it a different way.

Other than the hospital, please list the name of each facility and/or professional your spouse has treated with.

If you don't know the name of a provider or facility, please give us a best guess or tell us you don't remember and we will try to find it a different way.

Other than the hospital, please list the name of each facility and/or professional your child has treated with.

If you don't know the name of a provider or facility, please give us a best guess or tell us you don't remember and we will try to find it a different way.

Do you want/need additional treament for your injuries?

Yes

Please describe any additional treatment that you expect to receive for your injuries:

Does your spouse want/need additional treament for his or her injuries?

Yes

Please describe any additional treatment that your spouse expects to receive for their injuries:

Does your child want/need additional treament for his or her injuries?

Yes

Please describe any additional treatment that your child expects to receive for their injuries:

Please list the name and location of all pharmacies where you have your prescriptions filled:

Prior to this incident, who was your primary doctor? Please list his or her address and phone number.

Prior to this incident, who was your spouse's primary doctor? Please list his or her address and phone number.

Prior to this accident, were you visiting any medical providers for any reason other than routine check-ups and preventive care? If so, please list the name and contact information of each medical provider, your condition or diagnosis, when you began treatment, and the frequency of the visit(s).

If you ever had any other serious injuries, illnesses or a diseases that required treatment by a doctor, it is helpful for us to know about it now. This is particularly true if there is a connection with your present physical complaints. The defendant will obtain your medical and hospital records, insurance records, etc., and will have a complete history of your past medical condition.

Prior to this accident, was your spouse visiting any medical providers for any reason other than routine check-ups and preventive care? If so, please list the name and contact information of each medical provider, the condition or diagnosis, when they began treatment, and the frequency of the visit(s).

If your spouse has ever had any other serious injuries, illnesses or a diseases that required treatment by a doctor, it is helpful for us to know about it now. This is particularly true if there is a connection with your spouse's present physical complaints. The defendant will obtain their medical and hospital records, insurance records, etc., and will have a complete history of their past medical condition.

Employment

Did you miss any work as a result of the incident?

Yes

How much time did you miss due to the incident?

What was your pay rate?

If you can, also estimate the amount of money you have lost as a result of the incident.

Who was your employer at the time of the incident?

Leave blank if not working at the time of the incident.

What was your employment designation at the time of the incident?

Employee

Contract - 1099 Worker

Cash Only

Business Owner

Are you currently employed by the same company?

Yes

I am not currently working

I am working for a different company

Did you leave your employment because of the incident?

Yes

Who are you employed by now?

Have you routinely filed income taxes in the last three years?

Yes

Did your spouse miss any work as a result of the incident?

Yes

How much time did your spouse miss due to the incident?

What was your spouse's pay rate?

If you can, also estimate the amount of money your spouse has lost as a result of the incident.

Who was your spouse's employer at the time of the incident?

Leave blank if not working at the time of the incident.

What was your spouse's employment designation at the time of the incident?

Employee

Contract - 1099 Worker

Cash Only

Business Owner

Is your spouse currently employed by the same company?

Yes

I am not currently working

I am working for a different company

Who is your spouse employed by now?

Did your spouse leave their employment because of the incident?

Yes

Has your spouse routinely filed income taxes in the last three years?

Yes

Internal routing fields, please don't modify.

Final Question

THANK YOU FOR COMPLETING THIS FORM! You should always be completely free to be honest and candid with us. All of our communications, whether face-to-face, email or phone, are protected by the attorney-client privilege. We will lose our license to practice law if we violate the attorney-client privilege. We can fix almost any problem if we know about it in advance. We have seen many witnesses that tried to hide something and have it painfully exposed in a deposition or trial. By answering these questions fully and completely now, we can prepare you properly and -- usually -- keep the issue from ever coming up in the first place. Please let us know if you think we have missed any details that may be relevant to your case.

Wetherington Law Firm Intake

Basic Information

The Vehicle You Were Riding In

Your Automobile Insurance

Wrongdoers Insurance

Health Insurance

The Incident

Damages

Medical Treatment

Employment

Internal routing fields, please don't modify.

Final Question

Submitting Your Completed Form