Hall Law Firm
5037 Veterans Memorial Blvd, Suite 1D
Metairie, LA 70006
(504) 321-1246
Personal Injury Intake
Thank you so much for contacting our law office! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.
Privacy Policy
All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.
Your Social Security number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.
Social Security numbers are most often used to positively identify parties. Most courts require Social Security numbers of all parties in a case. Some other examples of how this information may be used include:
initial service
in court orders
in required reports or other documents filed with the State
If you have any questions, please don't hesitate to contact us. We look forward to working with you!
PERSONAL INFORMATION
Contact information
Prefix
First name
*
Middle name
Last name
*
Date of birth
Emails
Email Address
*
Type
Upon submission, a copy of this form will be sent to the primary email.
Work
Home
Other
Primary
Default email false
Add email
Addresses
Street address
Country
Australia
Canada
United Kingdom
United States
---------------
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Türkiye
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
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Venezuela
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Virgin Islands, British
Virgin Islands, U.S.
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Province/Region
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Work
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Home
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Primary
Default address false
Add address
Phone numbers
Phone number
Type
Work
Home
Mobile
Fax
Pager
Skype
Other
Primary
Default number false
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Preferred Contact Method
Select an option
Email
Phone Call
Text Message
No Preference
Gender
Male
Female
Social Security Number
Driver's License Number
Marital Status:
Single
Married
Spouse or Partner's Full Name:
Divorced
Widow(er)
Do you have any military service?
Yes
Dates of Service
Branch of Military
Any Military Service Related Injuries (describe)
Rank/Paygrade:
Were you dishonorably discharged?
No
How were you referred to our law firm?
Friend or family member
Input the person's full name:
Another attorney
Input the attorney's full name:
Online search or lawyer directory website
Input the name of the website:
For example, "Avvo", "Facebook", "Google", or website address, etc.
Billboard, bus stop, phone book, newspaper, or other physical advertisement
Where was the ad located?
Radio or TV advertisement
What radio or TV station?
Bar Association
Which Bar Association?
Other
Please explain how you found us:
ACCIDENT INFORMATION
Is this an auto accident?
Yes
Were you a driver, passenger or pedestrian?
What is the driver's full name?
No
What type of accident?
Date of Incident
Time of Incident
Indicate if AM or PM
City of Incident
Parish of Incident
Road/Intersection
if applicable
Were the police called to the scene?
Yes
Police Details
(Police Department Name, Officer's Name, Other Details)
No
Was an accident or incident report filed?
Yes
Report Number
Report Details
No
Unknown
Your understanding of how the incident occurred.
Please be as specific as possible.
Photo / Diagram Upload
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OTHER PARTY
If KNOWN / APPLICABLE
Name of Other Party
Other Party's Address
Other Party's Phone Number
Other Party's Job / Occupation
Other Party's Age
Other Party's Insurance Company
Other Party's Insurance Adjuster
Other Party's Insurance Coverage
Give your observations about the party as a person.
WITNESSES
IF APPLICABLE
Witness #1
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Telephone
What did this person witness?
Not Applicable
Witness #2
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Telephone
What did this person witness?
Not Applicable
Witness #3
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Telephone
What did this person witness?
Not Applicable
Witness #4
If applicable, please select "Fill out witness information" and complete the following information.
Fill out witness information
Name
Address
Age
Telephone
What did this person witness?
Not Applicable
Additional Witnesses or Information
STATEMENTS MADE
Have you told any police officer, investigator, insurance adjuster or any other person about the accident?
INJURIES AND SYMPTOMS
Please describe any and all aches, complaints, discomforts and disabilities, as a result of injuries related to the subject accident, in detail.
Check symptoms you have noticed since the accident
select all that apply
Back pain
Chest pain
Depression
Dizziness
Ears ringing / Buzzing in ears
Fainting
Fatigue
Feet cold
Hands cold
Headaches
Increased sensitivity to light
Loss of balance
Loss of memory
Loss of smell
Muscle soreness / pain
Neck stiffness / pain
Nervousness
Numbness in fingers / upper extremities
Numbness in toes / lower extremities
Other Numbness
Tingling / Pins & needles in fingers / hands / arms
Tingling / Pins & needles in toes / feet / legs
Problems sleeping
Shortness of breath
Tension
Upset stomach
Did you go to the hospital?
Yes
Name of Hospital
No
Did you go by ambulance?
Yes
Name of Ambulance Service
No
Did they take x-rays?
Yes
No
Have you seen a doctor since the date of the accident, other than at the emergency room?
Yes
Please list all doctors
name, address and telephone number, and dates of treatment
No
INJURY HISTORY
Have you had any accidents or injuries before this accident?
Past Injury #1
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Injuries sustained
Injury Treated by
Dates of treatment
Type(s) of treatment (i.e. physical therapy/chiropractic treatment; Epidural Steroid Injections; Surgery; etc.)
Where your symptoms resolved by the end of your prior treatment?
Not Applicable
Did you file a claim and/or lawsuit for Past Injury #1?
Yes
Did you receive a Settlement?
Date of Settlement?
Amount of Settlement?
No
Past Injury #2
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Injuries sustained
Injury Treated by
Dates of treatment
Type(s) of treatment (i.e. physical therapy/chiropractic treatment; Epidural Steroid Injections; Surgery; etc.)
Where your symptoms resolved by the end of your prior treatment?
Not Applicable
Did you file a claim and/or lawsuit for Past Injury #2?
Yes
Did you receive a Settlement?
Date of Settlement?
Amount of Settlement?
No
Past Injury #3
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Injuries sustained
Injury Treated by
Dates of treatment
Type(s) of treatment (i.e. physical therapy/chiropractic treatment; Epidural Steroid Injections; Surgery; etc.)
Where your symptoms resolved by the end of your prior treatment?
Not Applicable
Did you file a claim and/or lawsuit for Past Injury #3?
Yes
Did you receive a Settlement?
Date of Settlement?
Amount of Settlement?
No
Past Injury #4
If applicable, please select "Fill out injury information" and complete the following information.
Fill out injury information
Date
Place
Nature of Accident
Injuries sustained
Injury Treated by
Dates of treatment
Type(s) of treatment (i.e. physical therapy/chiropractic treatment; Epidural Steroid Injections; Surgery; etc.)
Where your symptoms resolved by the end of your prior treatment?
Not Applicable
Did you file a claim and/or lawsuit for Past Injury #4?
Yes
Did you receive a Settlement?
Date of Settlement?
Amount of Settlement?
No
Additional Past Injury and/or accident Information
LOSS OF EARNINGS
If you anticipate loss of earnings due to accident related injuries, please complete the following:
Are you currently employed?
Yes
Employer:
Length of Time with Current Employer:
Job Title:
Employer Address:
No
Are you paid hourly or salary?
Hourly
Rate of Pay
$____per hour
Salary
Yearly Salary
How many hours do you normally work per week?
Were you working at the time of the accident?
Yes
No
Have you missed any work as a result of the accident?
Yes
Amount of time missed
No
Do you anticipate missing any/any more work as a result of the accident?
Yes
No
Do you intend on making a claim for lost wages?
Yes
No
ADDITIONAL INFORMATION
Any additional Information you think would be helpful?
Please acknowledge that you have read and hereby accept the above privacy policy regarding use of personal information, and that submission of this form does not create an attorney client relationship, by typing your full legal name below
.........................
Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.
Please click the
SUBMIT
button below when you have finished answering all questions.