Questionnaire for Attorneys (Civil)

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1. Who are you representing in this case?
Plaintiff
Defense
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2. This case is related to:
Motor vehicle accident
Medical malpractice
Disability claim
Conservatorship/Guardianship
Estate Planning
Employment Law
Other Personal Injury non-work related
Other
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3. To your knowledge, has the Plaintiff already undergone a neuropsychological or psychological evaluation specific to this case?
YESNO
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If so, When (mm/yyyy) ? mm/yyyy
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4. Is there a timeframe in which the Plaintiff would need to be evaluated?
Within the next month
Within 2-3 months
Within 4-6 months
Undetermined
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Please provide your contact information:
Name:
Law Firm:
Phone:
E-mail:
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How would you prefer to be contacted?
Email
Phone
Text
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Please upload any relevant medical and/or legal records to our secure HIPPA compliant database, so that we may review the case appropriately prior to responding to this inquiry. Helpful documents can include: • Emergency department documents • Previous neuropsychological evaluation reports • Any brain/head neuroimaging result reports • Reports from specialty providers (e.g., neurology, physical therapy, chiropractor, psychologist, psychiatrist).
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