Intake Evaluation Form

The attorneys at Layman Law Firm ask their prospective clients to do the best they can in completing the required fields on this intake form.

Do not feel overwhelmed by the process.  We will have a productive first meeting even if you are not sure of all the information.  However, it is very helpful to have all the relevant information available to us from the beginning, as it will allow us to start the process sooner.  Please feel free to call our office if you have any questions.

Step 1.) Fill out the form below (Click here for the printable version that can be filled out and brought in).

Step 2.) If you have not yet, call the office to schedule an appointment with an attorney for the first consultation.

*Indicates a Required Field


    Intake Evaluation Form


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    Background Information


    MarriedSingleDivorcedSeparatedWidowed/Widower


    YesNo



    Occupation



    MonthlySemi-MonthlyBimonthlyWeekly


    YesNo


    YesNo


    Incident Information


    YesNo

    YesNo

    YesNo

    YesNo

    YesNo


    YesNo

    YesNo


    YesNo


    YesNo


    Your Automobile Insurance Information



    YesNo

    If you were either driving or a passenger in a vehicle not owned by you, please answer the following:


    Description of Vehicle Involved in Crash


    YesNo

    YesNo

    YesNo


    YesNo


    Workers' Compensation


    YesNo


    YesNo


    Health Insurance Information

    Please list information on ALL health insurance policies available to you from the date of the
    accident until today, including group or individual, Medicare, Medicaid (all companies from
    which you get Medicaid benefits) and all supplemental health insurance policies covering you. If you have been covered (since the date of the accident) by more than three health insurance
    companies, please use the back of this form to write the additional information.

    1. If you have had no health insurance coverage (from the date of the accident until today), please put "none" on Health Insurance Company 1.
    2. If you have Medicaid, please put WHY you qualify for this and list all Medicaid companies that you collect benefits from such as Florida Medicaid, Wellcare, Staywell, Medi Pass, Healthease, Amerigroup, United Health Care of Florida, etc. We need copies of all of the insurance cards from all of the companies you collect Medicaid benefits from.
    3. If you have Medicare AND ARE NOT 65 YEARS OLD, please put WHY you qualify for this.

    PLEASE PROVIDE US WITH A COPY OF ALL HEALTH INSURANCE CARDS. If you can't make copies, please bring the cards to our office so that photo copies can be made for our file.


    Disability


    YesNo

    YesNo


    At-Fault Party Information


    YesNo

    Was there more than one at-fault party? If so, list immediately below


    YesNo


    Witness Information

    Names of any witnesses: (Please include addresses and telephone numbers, if known.


    Injuries/Medical Treatment




    YesNo

    List ALL health care providers you have treated with for this accident including ambulance, hospital, treating doctors, family doctors, chiropractors, neurologists, orthopedists, MRI testing, physical therapy, massage therapy, CT scans, X-rays, etc.


    YesNo



    YesNo



    When are your next doctors' appointments?


    Prior Injuries and Medical Treatment

    Describe in detail each and every PAST injury, accident, including work-related accidents, in which you have ever been involved. (Include date, time, location, type of accident, and injuries.) even if you sustained no injury and/ or made no claim.

    Have you ever complained to or treated with any of the following PRIOR TO this accident?


    YesNo

    YesNo

    YesNo


    Additional Background Information

    YesNo
    YesNo


    YesNo

    YesNo



    PLEASE NOTE THAT THE FILING OF BANKRUPTCY DURING THE PENDENCY OF YOUR ACCIDENT CLAIM MAY ADVERSELY AFFECT YOUR CASE!


    YesNo

    Give the names, addresses and telephone numbers of two people who will always know where to reach you: