# Personal Injury Intake Form Template

> A free personal injury intake form for law firms. Potential clients describe the accident and injuries, and lead mode shows which cases to call first.

Screen every new personal injury inquiry with the accident type, date, injuries, fault and whether they already have a lawyer. Lead mode marks recent cases with treated injuries as hot leads.

Canonical: https://reuily.com/templates/personal-injury-intake-form
Use this template: https://reuily.com/form/from-template/personal-injury-intake-form
Collections: Marketing & Sales, Requests & Intake, Professional Services, Legal
Last updated: 2026-10-24

## Questions

- Question 1: What's your full name? (Short Text, required)
- Question 2: What's your email address? (Email, required)
- Question 3: What's your phone number? (Phone, required)
- Question 4: What kind of accident was it? (Single Choice, required). Options: Car or truck accident; Slip and fall; Injury at work; Dog bite; Something else
- Question 5: When did it happen? (Single Choice, required). Options: Within the last month; 1 to 12 months ago; 1 to 2 years ago; More than 2 years ago
- Question 6: Were you hurt? (Single Choice, required). Options: Yes, and I saw a doctor; Yes, but I haven't seen a doctor; No injuries
- Question 7: Who do you think was at fault? (Single Choice, required). Options: Someone else; Partly me; Not sure
- Question 8: Do you already have a lawyer for this? (Yes / No, required)
- Question 9: Describe what happened (Long Text, required)
- Question 10: Upload photos or a police report (File, optional)
- Question 11: When is the best time to call you? (Single Choice, required). Options: Morning; Afternoon; Evening

## Common uses

- Personal injury law firms
- Car accident case screening
- Landing pages for injury ads

## Key features

- Accident and injury details
- Photo and report uploads
- Hot lead tagging

## Frequently asked questions

### How does lead mode screen injury cases?

It reads the accident date, injuries, fault and whether they already have a lawyer. Recent cases where someone else was at fault and the person saw a doctor come through as hot leads.

### Where should a personal injury firm use this form?

Put it on your website, in injury ad landing pages, and in text replies to missed calls, so every inquiry gets screened the same way.

### Does submitting the form make someone a client?

No. The thank you message says sending the form does not create a lawyer and client relationship. You decide which cases to take after you speak.