client intake form

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

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Shared by: robert myers
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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: Address: Phone: Timothy Cowling (through Sandra Cowling, next friend) 4424 High St., Lansing, MI 48917 (517) 371-5555 SS# 123-45-6789 Driver License #: None Insurance: None Education: 3rd Grade Employment History Current: At time of incident: Prior Employment: Reason for leaving: None None None 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. 1 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: Current Injuries: Current Physician: Treating Physicians: Broken right arm (radius bone) at age 5 Broken right arm (ulna), fractured lumbar vertebra, deep facial lacerations and scarring Pediatrician (name currently unknown) 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. 2 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. 3

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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...)
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