Free Case Evaluation

Your Name*:

Your Relation to Injured Party (Self, Spouse, Parent, etc.)*:

Full Name of Injured Party*:

Age of Injured Party*:

Date of Injury*:

Occupation and Yearly Salary of Injured Person*:

Does Injured Party Have Children? (Number, Ages, Names)*:

Where Did the Injury Occur? (City and State)*:

If Injury Occurred in a Hospital or Emergency Department, Name Hospital*:

If Injured Party Was Discharged from a Hospital Prior to the Injury, List the Date He/She Was Released and the Date of Attempted or Completed Suicide*:

If Injured Party Was in Outpatient Care, What Was the Time (in Days or Hours) from the Last Contact with the Outpatient Clinician until the Attempted or Completed Suicide?*:

Name & Addresses of Persons or Entities You Feel Caused the Attempted or Completed Suicide*:

If Injured Party Did Not Die of Suicide, Describe the Injuries*:

Case Overview (Other Details You Wish to Add)*:

Approximate Cost of Medical Bills*:

Approximate Cost of Lost Wages or Benefits*:

Are You in Contact with Another Lawyer?*: YesNo

If So, Please Provide the Attorney's Name, Address, and Phone Number*:

Has Any Lawyer Rejected the Case?*: YesNo

Email*:

Phone*:

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