619-333-5100
mike@goldfadenbenson.com
1245 Island Ave 2nd Fl, San Diego, CA 92101

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- Michael J. Goldfaden
- Matthew S. Benson
Michael J. Goldfaden

Matthew S. Benson
Practice Areas
- Wildfire Law
Personal Injury

Auto Defect

Bad Faith Insurance Lawyer

Bicycle Accident

Bus Accident

Car Accident

Defective Medical Device

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Falling Object Injury

Food Poisoning

Medical Malpractice

Motorcycle Crash

Pedestrian Accident

Pharmaceutical Injury

Truck Accident

Employment Law

Family Medical and Parental Leave

Harassment at Work

Misclassification

Wage and Hour Violations

Workplace Discrimination

Wrongful Termination

Consumer Law

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Contact Us

Client Questionnaire

Please fill out the form below so that we can thoroughly evaluate your case and determine whether or not an attorney-client relationship is in your best interest. Note that unless and until a retainer agreement is signed, no attorney-client relationship has been formed.

Client Questionnaire

Please fill out each field to the best of your ability.

Identifying Info and Background

First Name(Required)

Every other first name you have used in the past, and the dates you used those names

Name

Dates

Last Name(Required)

Every other last name you have used in the past, and the dates you used those names

Name

Dates

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Any other addresses you've used in the last 5 years, and dates of each

Phone number(Required)

Email(Required)

Date of birth(Required)

Month

Day

Year

Social Security Number

Are you married?

Yes

Spouse's name

Spouse's phone number

Do you have children?

Yes

List their name(s) and age(s)

Employer name

Employer address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer phone number

Job title

Dates of employment

Salary

List each school / academic or vocational institution you've ever attended, and any degrees received

Name of institution

Degree received (if any)

Have you ever been convicted of a felony?(Required)

Yes

City and State convicted

Date of conviction

Month

Day

Year

Offense

Court and case number

Incident Info

Date and Time of Injury(Required)

Date of Injury in Date Format(Required)

MM slash DD slash YYYY

Location of incident(Required)

Incident summary(Required)

Be specific (if driving, what direction were you driving, what freeway or street, were you at a stop, were you slowing down, where were your hands and feet, did you hit any body parts on anything in the car, did you lose consciousness, etc.)

Name all those responsible for your injury(Required)

Were there witnesses?

Yes

List witness names, contact info, and any relevant information about how you were injured

At the time of the incident, did you have a driver's license?

Yes

State the state issuing, license number and type, date of issuance, and all restrictions

Describe in detail the physical, mental, and emotional injuries you suffered, including what part of your body was injured and how(Required)

Were you hospitalized?

Yes

List your admission and discharge dates, the hospital name, and who treated you

Describe all surgeries (if any)

List any future medical care you may need (and which doctors informed you of this)

Prior to the accident, have you had any treatment or complaints, whether physical, mental, or emotional?

Any previous work injuries, slips and falls, or car accidents? List dates and details

Are you happy with your medical care to date? If not, why?

Include any other injuries that occurred as a result of your accident which have not been treated

Have you missed work due to the accident? (How many days/hours)

Describe all the problems you have experienced with each of your injuries

Such as level of pain, decreased mobility, inability to do the things you once could, etc.

Have you consulted with a psychologist, psychiatrist, or mental health care provider?

Yes

If not, would you like to?

Yes

List all CURRENT health care providers, including your primarty care physician

Do you have any photos, video, or other documentation relating to the incident? If so, please describe

Has any insurance provider paid for any medical bills or other loss you have suffered? If so, please list the insurance provider

Have you ever received disability, social security, or any other funds relating to your injury?

Yes

Are you currently in the process of applying for any such funds?

Yes

Name

This field is for validation purposes and should be left unchanged.

Michael J. Goldfaden

Matthew S. Benson

Personal Injury

Employment Law

Consumer Law

Wildfire Law

Premises Liability

Articles

News

Bar Bites Podcast

Client Questionnaire

Client Questionnaire

Identifying Info and Background

Incident Info