PERSONAL INJURY CLIENT INTERVIEW SHEET
FILE NO. _____________ D/I ____________ SOL ____________ TYPE CASE __________
OPENED ___________ SOURCE ___________________ LAWYER ____/____ LA _______
CLIENT INFORMATION:
________________________________________________________________________
NAME (First, Middle, Last) NAME CALLED
________________________________________________________________________
CLIENT GUARDIAN (If Minor) NONCUSTODIAL PARENT
______________________________________________________________________________
CLIENT MAILING ADDRESS STREET ADDRESS (If Different)
______________________________________________________________________________
CITY STATE ZIP
HOME PHONE________________________ WORK PHONE ___________________________
OTHER PHONE ___________________ NAME & RELATIONSHIP _____________________
AGE _____________________ EDUCATION _______________________________________
CLIENT D.O.B. ___________________________ CLIENT SS NO. ______________________
MARITAL: Married/Single/Divorced/Widowed/Separated _______________________________
Date
SPOUSE/PARENT GROUP INSURANCE Y/N _______________________________________
Company
OTHER HEALTH INSURANCE/MEDICARE/MEDICAD ______________________________
Company
CRIMINAL RECORD ___________________________________________________________
WORK INFORMATION:
______________________________________________________________________________
CLIENT’S EMPLOYER DATE EMPLOYED
______________________________________________________________________________
EMPLOYER’S ADDRESS (Street, City, State, Zip)
LOST WAGES Y/N JOB TITLE ___________________ RATE OF PAY ________________
HRS/WK _______________ SHIFT/HOURS ____________ SUPERVISOR _______________
STD/LTD/SICK PAY Y/N ________________________________________________________
Company