Wilson & Wilson, P
PERSONAL INJURY
Before your meeting with the attorney complete the following forms:
Client Information Sheet
Personal Injury Information Sheet
Return the forms via:
1. Bring to your appointment
2. Email to admin@
3. Fax to 757-873-1938
Also, bring your police report, witness statements, photographs and any other documentation you have regarding the incident.
Make sure all questions are answered
WILSON & WILSON, P.C.
Client Information Sheet
Today’s Date: __________________
The purpose of a legal consultation is to advise you of your legal position, the strengths and weaknesses of your case, and options available to you. You will be given an estimate of the legal fees and court costs you can anticipate.
Be assured that everything you discuss in this office and on this form is strictly confidential.
There is no consultation fee if you are a bankruptcy, traffic, criminal, personal injury, court appointed or a Legal Resources client.
For all other clients, a $100.00 consultation fee should be paid to the receptionist prior to your consultation and will be credited to your retainer amount, should you choose to retain the firm within six (6) weeks. Checks, cash, Visa, MasterCard, American Express and Discover are acceptable. Charge and debit cards are subject to a 3% processing fee.
Name (include maiden): ___________________________________________________ Birth Date: _________________________
Address: __________________________________________ City: _________________ State__________ Zip Code: ___________
Social Security Number: _____________________________________ Email Address: ___________________________________
May we correspond via email? Yes No If No, what is preferred method of correspondence? _______________________
Telephone No.: (H) ___________________ (W) ___________________ (C) ___________________ Fax _____________________
What is preferred phone number? Home Work Cell Other: _________________________________
Employer’s Name: ___________________________________________________Your position: ___________________________
EMERGENCY CONTACT INFORMATION
Emergency Contact: ________________________________________________Relationship: ______________________________
Telephone Number: (H) ___________________________ (W) ____________________________ (C) _______________________
Address: __________________________________________________________________________________________________
I came to Wilson & Wilson, because:
___ I was referred by (an attorney, a Wilson & Wilson client, etc.): _____________________________________________________
___ Legal Resources ___ Yellow Pages ___ CLC ___ Internet-Which Site?_________________
___ Court Referral ___ Local Edge ___ ___ I am a previous client-when? _____________
___ VA Lawyer Referral Service ___ Other (Please Specify): ____________________
Matter you wish to discuss:
___ Personal Injury ___ Divorce ___Traffic Charge
___ Bankruptcy ___ Support ___ Criminal Charge
___ Name Change ___ Custody ___ CLC
___ Separation Agreement ___ Visitation Other (Briefly Describe): ___________________________________
If you have a court date or deadline, please state when and where: _____________________________________________________
Name of adverse Party (Party who sued you or you want to sue, including maiden name): __________________________________
DO NOT WRITE BELOW THIS LINE – FOR OFFICE USE ONLY __________________________________________________________________________________________________________
Open File______ Court Date: _________________ CMW___ RSM___ Court: _______________________________
Adverse Attorney: ___________________________________________ Phone: __________________________
Thank – You to be sent to:_____________________________________ Date Sent: ______________________
WILSON & WILSON PERSONAL INJURY INFORMATION SHEET
Date of Accident:____________ Statute of Limitation or Notice of Claim:_____________________
Need for Plaintiff or Defendant: Guardian Ad Litem? __________
Administration_______________
Plaintiffs
1. Name: ___________________
Address:___________________________________________
Home Phone: ___________________________
Other Phone: ____________________________
Fax: ___________________ E-mail: _____________________
2. Name: ___________________
Address:___________________________________________
Home Phone: ___________________________
Other Phone: ____________________________
Fax: ___________________ E-mail: _____________________
3. Name: ___________________
Address:___________________________________________
Home Phone: ___________________________
Other Phone: ____________________________
Fax: ___________________ E-mail: _____________________
Defendants (Specify individual, agent, partnership, corporation, etc.)
1. Name: _____________________________________________
Address:_____________________________ Age (if minor): __________
2. Name: _____________________________________________
Address:_____________________________ Age (if minor): __________
3. Name: _____________________________________________
Address:_____________________________ Age (if minor): __________
4. Name: _____________________________________________
Address:_____________________________ Age (if minor): __________
Referring Attorney(s): ____________________________________________________
Other referral:___________________________________________________________
Facts of Occurrence
1. Scene: _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
2. Direction of vehicles: ______________________________________________________
______________________________________________________
______________________________________________________
3. Weather & Road Conditions: ________________________________________________
________________________________________________
________________________________________________
4. Time: ________________ Day of Week:__________________________________
5. General Facts of Occurrence: __________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
6. Police at Scene: _____________________________________________________
7. Arrests: ____________________________________________________________
8. Plaintiff Vehicle, Type, & Location: ______________________________________
______________________________________
License No.:_______________ Photos?______________________
9. Defendant Vehicle, Type, & Location: _____________________________________
______________________________________
License No.: ________________ Photos? _______________________
10. Witnesses (including ambulance, tow truck, post-occurrence, “My Day,” etc.)
(Name) (Address) (Type and/or location of witness & phone)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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