Personal injury intake form template
This six-step personal injury intake form asks the losses suffered, the type of accident, how long ago it happened, the ZIP code and any notes, followed by the contact details. Clone it into your Growform account and edit any question.
What the form asks, step by step
The form opens with the losses rather than the accident, because that is what the claimant is thinking about. Timing and location follow, and those are the facts an intake team screens on.
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Step 1: “Have you suffered from any of the following?”
Ten types of loss, from medical costs to lost earnings, can be selected together.
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Step 2: “What type of accident did you have?”
Car, construction and workplace accidents usually go to different attorneys.
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Step 3: “How long ago did it happen?”
Time bands flag older claims against the statute of limitations early.
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Step 4: “What’s your ZIP code?”
The ZIP code confirms the claim falls within your state or referral network.
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Step 5: “Is there anything else we should know?”
Claimants describe their injuries and circumstances in their own words here.
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Step 6: “How shall we get in touch about your claim?”
Name, email and phone come last.
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After submitting
The claimant presses “Send my report” and sees a thank-you screen, which a firm would change to explain the free case review.
Who it’s for
Personal injury firms, legal marketing agencies and claims companies use this template on landing pages for accident claims. It works as a law firm intake form for the first contact and collects what the intake team screens on, which is the loss, the accident, the timing and the location. Cases outside your practice area or jurisdiction can be referred on without a long call. The headline promises to show what compensation the claimant is owed, so check it against the advertising rules for lawyers in your state. The guide to legal intake forms shows how one form can serve several practice areas.
Why this structure converts
- Starting with the losses lets the claimant describe the impact first, which is why they are looking for a lawyer.
- Accident type and timing are single taps, so the screening questions take seconds to answer.
- The ZIP code is asked before the contact details, so out-of-state inquiries can go straight to a referral partner.
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Make it yours
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Correct the accident options
One accident option is misspelled as “Addicent at work” in the template. Correct it, and add the case types you take, such as slip and fall or medical negligence.
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Branch by accident type
Use conditional logic to ask car accident claimants whether a police report was filed and workplace claimants whether the accident was reported to the employer.
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Send cases to your case system
Connect the form to Clio, Lawmatics or Filevine so each inquiry opens as a lead with the answers attached.
Frequently asked questions
What should a personal injury questionnaire ask at first contact?
It should ask what the claimant lost, what kind of accident caused it, when it happened and where. Medical records and insurance details come later, once the firm has agreed to review the case.
Is this a legal intake form for every practice area?
It is written for personal injury. The structure suits any legal intake form, and you can replace the loss and accident steps with the questions your practice area needs.
Can I filter out older claims?
Yes. The timing step uses bands, and conditional logic can show a different message to claimants whose accident was more than twelve months ago.
Which legal CRMs does it work with?
Submissions can go to Clio, Lawmatics, Filevine or Lawcus, and to general tools such as HubSpot and Slack.
What happens next?
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Step 1: Clone this form template
Clone this template into your Growform account (create one first if you don’t already have one). -
Step 2: Edit your form
Get creative and adjust your form's theme options, questions or layout in the Growform form builder. -
Step 3: Share or embed your form
Share a link to your form, or embed it in your existing website. Receive new submissions by email or send them to 7,000+ apps via Zapier.
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