440 Louisiana Street, Ste 900

    Houston, Texas 77002

    Ph: (713) 804-9118 

    Fax: (346) 585-0121 

    Email: office@pinnaclelawgrouphtx.com

Personal Injury Initial Intake Form

Thank you so much for contacting the Pinnacle HTX Law Group PLLC! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation.

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security numbers are most often used to positively identify parties. Most courts require Social Security numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you! To return to the website, please click here. 


This section collects contact details for the injured party. Please provide the following information:

    • Full Legal Name
    • Address(es):
            • Physical address
            • Mailing address, if different
    • Telephone number(s):
            • Your best contact number
            • Alternate contact numbers
    • Email address
    • Date of Birth
To add any additional addresses or telephone numbers, if applicable, clickunder the address/telephone number/email section.

Please note: If the injured party is a minor, enter the minor's information here. You will be asked for parent or guardian information in the section below.

Contact information: Injured Party

Emails
*
Upon submission, a copy of this form will be sent to the primary email.
Add email
Addresses
Add address
Phone numbers
Add phone number


Please provide the name, relationship, phone number, and email of someone we may contact on your behalf in the event we are unable to reach you.

 If the injured party is a minor, please include the parent or legal guardian's contact information in this section.

Contact information: Emergency Contact/ Parent/Guardian

Emails
*
Add email
Addresses
Add address
Phone numbers
Add phone number

Please indicate whether the time was AM or PM.

If you were injured in a car accident, skip this question. If injured on someone else's property, indicate whether you had permission to be there (for example, you were invited, or entered as a customer) or were present without the owner's consent.

i.e. damages to the vehicle, broken signages, drove into storefront, dog damaged fence, etc.


Thank you for taking the time to complete this form. 


If you are not ready to submit the form yet, please click “Save Progress and Exit.” You may return to the form anytime using the link that was emailed to you. 


When you are finished, please click “Submit.” After submission, an email confirmation will be sent to you. If a consultation has not yet been scheduled, we will contact you as soon as possible unless otherwise stated.