Word Document

client intake form

You must be logged in to download this document
Description

sample form to use on or about first meetings with client.

Reviews
Shared by: robert myers
Categories
Tags
Stats
views:
331
downloads:
2
rating:
not rated
reviews:
0
posted:
3/3/2008
language:
English
pages:
0
1 Tombers and Associates, PC 300 South Capitol Avenue Lansing, Michigan 48933 517.371.5140 tomberse@cooley.edu ___________________________________________________________ ____ CLIENT INTAKE SHEET1 Case: Timothy Cowling v. International Department Store and Sam Security Filing Deadlines: April 1, 2005 (negligence) April 1, 2004 (false imprisonment) April 1, 2005 (intentional infliction of emotional distress) Interview Date: March 17, 2003 Client Name: Timothy Cowling (through Sandra Cowling, next friend) Address: 4424 High St., Lansing, MI 48917 Phone: (517) 371-5555 SS# 123-45-6789 Driver License #: None Insurance: None Education: 3rd Grade Employment History Current: None At time of incident: None Prior Employment: None Reason for leaving: N/A (not applicable) Parents Names: Sandra Cowling DOB: 5/13/70 Need to get father’s name 1 Originally prepared by student Marilyn Tombs in Michaelmas Term 1998. 2 CASE BACKGROUND Opposing Party: International Department Store and Sam Security Counsel: Andrew Quinn (P33333), 217 S. Capitol Ave., Lansing, MI 48933 (517) 555-1212 Type of Incident: Negligence Location: Big Mall, 2000 W. Saginaw Hwy., Lansing, MI 48917 Time: Approximately 11:30 a.m. Date: April 6, 2002 Reason for seeking Counsel: Initiate lawsuit Referred by: N/A Witnesses: Sarah Sawitall 200 Elm St. Lansing, MI 48933 Clarence Confused 341 Poorvision St. Lansing, MI 48911 CLIENT HEALTH Past Injuries or Illnesses: Broken right arm (radius bone) at age 5 Current Injuries: Broken right arm (ulna), fractured lumbar vertebra, deep facial lacerations and scarring Current Physician: Pediatrician (name currently unknown) Treating Physicians: Will Treatum, M.D. (orthopedic surgeon) I.M. Nutt, Ph.D. (psychologist) DAMAGES Ms. Cowling does not have health insurance for her family. To date, she has been billed $20,000.00 for Timothy’s treatment. Timothy will need more surgery and continuing counseling. Timothy is still in pain and suffers from nightmares. SUMMARY OF FACTS On April 6, 2002, Timothy Cowling and his mother, Sandra Cowling, were at the International Department Store at the Big Mall on the west side of town. Ms. Cowling allowed Timothy to stay in the home electronics department while she went to the linens department to make a quick purchase. A gang of older boys, the Young Hoods, entered the home electronics department and began creating a disturbance. Timothy was quietly playing a video game. 3 Sam Security, a big, burly security guard, thought the youths had stolen something and rounded them all up, including Timothy. He took them to the security office and interrogated them for about 25 minutes. He ejected all of the boys from the store, including Timothy, and told them not to come back in. The Young Hoods again began roughhousing. One of them knocked Timothy off of the sidewalk and into the path of an oncoming car. Timothy was struck by the car, whose driver immediately fled. Neither the car nor the driver have been found.
Shared by: robert myers
About
Grew up in mainland US (mostly coastal), since Dad was USN. Dad met mom when stationed in Guam & went back to states. Mom born on Rota, Northern Mariana Islands (now a US Territory). Picked to make my home on islands because of be (More...)
Other docs by robert myers
motion for summary disposition
Views: 751  |  Downloads: 18
response to motion for summary disposition
Views: 706  |  Downloads: 23
litigation chart or table
Views: 452  |  Downloads: 28
investigation plan
Views: 281  |  Downloads: 1
alternative dispute resolutoin letter to client
Views: 270  |  Downloads: 5
hourly agreement
Views: 306  |  Downloads: 10
Related docs
client intake form
Views: 331  |  Downloads: 2
Basic Client Intake Form
Views: 6  |  Downloads: 0
BUSINESS CLIENT INTAKE FORM
Views: 181  |  Downloads: 5
CLIENT INTAKE FORM
Views: 224  |  Downloads: 7
Copy of CLIENT INTAKE FORM
Views: 166  |  Downloads: 1
Copy of BUSINESS CLIENT INTAKE FORM
Views: 100  |  Downloads: 1
BUSINESS CLIENT INTAKE FORM[1]
Views: 41  |  Downloads: 2
LEGAL ASSISTANCE CLIENT INTAKE QUESTIONNAIRE
Views: 31  |  Downloads: 0
No Longer Client Form Template
Views: 145  |  Downloads: 7
Client Acceptance Form Template
Views: 421  |  Downloads: 18
Client Change - Inactivation Form
Views: 128  |  Downloads: 4
BANKRUPTCY REQUEST FORM CLIENT NAME
Views: 4  |  Downloads: 0
Client Set-Up Form template
Views: 351  |  Downloads: 14
Employees' Client Referral Form Template
Views: 148  |  Downloads: 4
Client Change of Address Form template
Views: 109  |  Downloads: 7