iReclaim Health — Referral / Intake Form

Law Firm

Keeps the records and correspondence we send back matched to your file reference

Firm Name *

Case / File Number *

Your internal reference — appears on all records and correspondence we send back

Attorney

Primary contact for clinical records and case-related updates

Attorney Name *

Email *

Phone

Case Manager / Paralegal

Day-to-day contact for scheduling and status — keeps things moving without pulling the attorney in

Name

Email

Phone

Client / Representative

Who we'll be treating — we handle all outreach, scheduling, and follow-up directly

Client Name *

Address

Phone *

Email

Date of Birth (MM/DD/YYYY) *

Date of Accident (MM/DD/YYYY) *

Used at clinical intake to document the date of injury

Post-Accident Wellbeing Check

Complete with the client — surfaces psychological injury early, when treatment can be most effective

Since the accident, has the client experienced any of the following?

1. Unwanted memories or bad dreams about what happened?

Yes No

2. Avoiding driving, riding in a car, or anything that reminds them of the accident?

Yes No

3. Feeling more on edge, jumpy, or having trouble sleeping?

Yes No

4. Feeling down, stressed, or not interested in things they normally enjoy?

Yes No

5. Feeling more anxious or unsafe than before the accident?

Yes No

6. Has it been harder to work, focus, drive, or handle daily tasks?

No Somewhat Yes, definitely

7. Since the accident, would you say the client is:

Getting better About the same Getting worse

Red flags — check any that apply Trouble sleeping most nights Trouble concentrating or remembering things Panic or anxiety attacks Missed work because of how they feel Afraid to drive or be in a car

If the client mentions thoughts of self-harm or suicide, treat it as urgent — call or text 988 (Suicide & Crisis Lifeline).

Referral / Intake Information Form

Law Firm

Attorney

Case Manager / Paralegal

Client / Representative

Post-Accident Wellbeing Check

Submitting the Form