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EST. 2026 · PI INTAKE
Free personal injury intake form

Free personal injury intake form

The questions Della asks on every injury call, readable on this page, printable as a PDF, and available as an editable template by email.

Read the form

Written for personal injury intake · Never assesses the claim · Free to use

Last updated

Sample dossier. A test caller, not a real one.

What is this personal injury intake form?

A personal injury intake form is the set of questions a law firm asks an injured caller on the first call: who they are, what happened, the injuries and treatment, fault, insurance, witnesses and any prior lawyer. This one is the script Della runs at night. In Clio's 2024 secret-shopper study only 40% of firms answered that call. (Oklahoma Bar Journal, 2025)

What goes missing without a form?

  • A message that says “car accident, please call” and nothing else.
  • Notes from the associate's cell phone with the incident date missing, so nobody has checked the limitations deadline.
  • A second call to ask the questions that should have been asked the first time, to a caller who has already rung the next firm.

An ABA Law Practice Division survey, reported by Lawyers Mutual NC (2019), found 42% of callers waited three days or more for a reply. A form fixes the second call. Answering the first one is a separate problem, covered on the personal injury answering service page.

The personal injury intake form

Seven sections, in the order Della asks them. Print this page or save it as a PDF from your browser. Call Della's playbook explains what should be on a PI intake form and why each question is there.

Personal injury intake form: the questions in order
SectionQuestions
Caller
  1. Full name
  2. Callback phone and whether texts are fine
  3. Email
  4. Best time to call back
  5. Are you calling for yourself or for someone else, and what is the relationship?
Incident
  1. What happened, in your own words?
  2. Date and time
  3. Where did it happen: city, state and the kind of place (road, store, workplace, property)?
  4. What kind of incident: vehicle, slip and fall, workplace, product, dog bite, other?
Injuries and treatment
  1. What injuries do you have?
  2. Did you go to the ER, urgent care or a doctor, and when?
  3. Are you still being treated, and by whom?
  4. Were you in pain or unable to work afterwards?
Fault and police
  1. Who do you believe was at fault, and why?
  2. Did police attend? Is there a report number?
  3. Was anyone cited or arrested?
Insurance
  1. Do you have auto, health or other insurance that applies?
  2. Do you know the other party's insurer?
  3. Has a claim been opened, and have you spoken to any insurer or given a statement?
Witnesses and evidence
  1. Were there witnesses? Names and numbers if you have them
  2. Photos, video, dashcam or a damaged item you still have?
Prior lawyers
  1. Have you spoken to or hired another lawyer about this?
  2. Have you signed anything with anyone about this incident?

Get the editable personal injury intake form template

Leave your name, work email and firm and we will send the template as a document you can change. If you would rather email, hello@calldella.com works too.

By submitting, you agree to our privacy policy. No spam, no sharing.

Privacy: we use your email to send the template and, if you ask, to arrange a demo. Nothing else.

How Della uses this form at night

She answers in your firm's name, opens with a recording disclosure set for your state and asks these questions one at a time, in this order, adjusting to what the caller has already said. She scores every caller for urgency and alerts the attorney on call by email when a call cannot wait. Every call becomes a dossier with a summary, urgency score, recording and transcript, on your desk by 7am. The personal injury intake page explains why each field matters to the attorney.

Hear the form run as a call

Book a 30-minute demo and listen to Della take an injury call using these questions, then see the dossier she files. Below is a sample, with a test caller.

SAMPLE · INTAKE DOSSIER · TEST CALL
Personal injury intake
URGENT
Caller
Test Caller A
Matter
Rear-end collision, Tuesday 9:42pm
Injuries
Neck and back pain, ER visit the same night
Fault
Other driver at fault, police report filed
Insurance
Other driver's insurer named
Urgency
4 of 5
Callback
Number captured
Sample: a test call, not a real caller
FAQ

Questions about the intake form

Is this personal injury intake form free to use?

Yes. Read it, print it or save it as a PDF from your browser, and use it in your own intake. The editable template is the same questions in a document you can change. Email us for it, or use the form on this page when it is live. Nothing here is legal advice, and the form never assesses a claim.

What should a personal injury intake form leave out?

Anything that assesses the claim, quotes a fee or tells the caller they have a case. Those are decisions for the attorney, made after the facts are in. The form should also avoid asking for medical records or statements on the first call. Capture where they are and who holds them, and request them once the firm has taken the matter.

Why does the incident date matter most?

Because it sets the statute-of-limitations clock, and the deadline varies by state and by the kind of claim. An intake form that captures the date, the state and the kind of incident lets the attorney check the deadline before the first callback, and lets the urgent cases, where the deadline is close, go to the front of the queue.

Is this allowed under bar rules?

Della never gives legal advice, never quotes fees and never implies the firm has taken the case. She collects facts, and you decide what happens next. Every call opens with a recording disclosure set for your state. Call Della's compliance guides on calldella.com cover ABA Formal Opinion 512 and consent by state.

Will callers mind speaking to an AI?

Della introduces herself by name, speaks calmly and asks one question at a time. If a caller asks whether she's an AI, she tells them. Every call is recorded, so you can hear exactly how each caller was treated. Book a demo, listen to a live injury call, and judge the conversation for yourself.

What does it cost?

Solo is $329 a month with 300 minutes, built for solo lawyers. Practice is $598 a month with 600 minutes. Both include the Call Della dashboard, urgent-call email alerts and a morning brief by 7am. Group is priced to your volume and adds custom minutes, priced to your volume, more than one practice area, cRM webhook. Extra minutes are $0.50 each. Every plan is month-to-month with no setup fee.

Sources

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