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Invasion of Privacy Claim: Attorney Intake Form

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Privacy is a more highly prized right the more technology intrudes into our lives. Sometimes, you may feel that your privacy has been violated, and in some instances, you may have legal rights against the person who invaded your privacy. This form can help you and your attorney determine whether your legal privacy rights have been injured and whether you can recover for that violation.

 

Attorney Intake Form:  Invasion of Privacy

 

Name: _________________________________

Address: _______________________________

_______________________________________

 

Telephone Number Work: _________________________

 Home:  _______________________

 

Employer’s Name: _______________________________

 

Employer’s Address:    

____________________________________

____________________________________

____________________________________

 

May we contact you at work?  Yes  _______   No _______

 

Why do you need legal advice about claims for invasions of privacy? 

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

Section I:   If You Think Your Privacy Has Been Invaded or Compromised

1.   Somebody has intruded on my privacy by coming into or peering into my home, listening to my private conversations, calling me all the time on the telephone, going through my things, or something similar.  Yes  _______            No _______

 

2.   If the intrusion did not happen at your home, were you in a public place?

Yes  _______            No  _______

 

3.   Where were you?     _________________________________________________

 

4.   Please provide a brief description of what has happened.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

5.   Somebody has revealed something private or embarrassing about me that should have been kept confidential.                            Yes  _______            No  _______

 

6.   Was the disclosure made public?     Yes  _______          No  _______

 

7.   If you answered “Yes” to question 6, please describe how and where the disclosure was made public.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

8.   Please describe what was disclosed or the nature of the disclosure.  A general description, like “revealed my medical records,” or “revealed something about my past” is perfectly fine at this point.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

9.   Somebody has done something that has conveyed a false impression about me to the public.

Yes   _______            No _______

 

10.  Please provide a brief description of what has happened.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

11.  How, or in what way, did this act place you in a bad light to the public?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

12.  Somebody has used my name or my likeness without my permission.

Yes  _______            No  _______

 

13.  How is your name or likeness being used?

_________________________________________________________________________

_________________________________________________________________________

 

14.  Did you give the person permission to use your name or likeness?

Yes _______            No  _______

 

15.  Did you withdraw that permission?

Yes  _______            No  _______

 

16.  Has someone been impersonating you?

Yes _______            No  _______

 

17.  If you answered “yes” to question 16, what has that person been doing while pretending to be you?

__________________________________________________________________________

__________________________________________________________________________

 

18.  Is the person using your name or likeness using it to his or her own profit or advantage?

Yes  _______            No _______

 

19.  How long ago did the incident(s) occur? 

In the last year   _______

More than one year ago    ______

More than two years ago   ______

More than three years ago ______

 

20.  If you know the precise date, please write it here:  ______________________________

 

Section II:  If You Are Being Sued

1.   Somebody has accused me of going into or peering into his or her home, eavesdropping, making prank or “hang-up” calls, going through his or her things, or something similar.

Yes  _______            No  _______

 

2.   Did the alleged invasion occur in a public place?

Yes  _______            No  _______

 

3.   Where were you?     _________________________________________________

 

4.   Please provide a brief description of what the accusation is.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

 

5.   Somebody has accused me of revealing something private or embarrassing that should have been kept confidential.                   Yes  _______            No  _______

 

6.   If you did in fact reveal something, what were the circumstances, who did you reveal it to, and why?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

7.   Was the disclosure made public?                 Yes  _______            No  _______

 

8.   Please describe what you are accused of disclosing.  A general description, like “revealed confidential records,” or “revealed something about the plaintiff’s past” is perfectly fine at this point.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

9.   Somebody has accused me of doing something that has conveyed a false impression about him or her to the public.                              Yes  _______            No  _______

 

10.  Please provide a brief description of what has happened.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

11.  Somebody has accused me of using his or her name or likeness without permission.

Yes  _______            No  _______

 

12.  In what way does the plaintiff contend you are using his or her name or likeness?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

13.  Did you have, or once have, the plaintiff’s permission to use his or her name or license?

Yes  _______            No _______

 

14.  If you had permission, was it withdrawn?      Yes  _______            No  ________

 

15.  Please explain your answer to question 14.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

16.  Someone has accused me of impersonating him or her.

Yes  _______            No  _______

 

17.  If you answered “yes” to question 16, what does the plaintiff contend you have being doing during the impersonation?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

18.  If you have been using the plaintiff’s name or likeness, has there been any profit or advantage to you?          Yes   _______            No  _______

 

19.  How long ago did the incident(s) occur? 

In the last year                             _______

More than one year ago                 _______

More than two years ago                _______

More than three years ago              _______

 

20.  If you know the precise date, please write it here:  _____________________________

 

21.  Do you have liability insurance?       Yes  _______            No/Not Sure  _______

 

If you do have liability insurance, please take a copy of it, along with any amendments or riders to it, with you to the first meeting with your attorney.

Next Steps
Contact a qualified personal injury attorney to make sure
your rights are protected.
(e.g., Chicago, IL or 60611)

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