Meeting with an Attorney: Mold Case Attorney Intake Form

 

Personal Information

Last Name: _______________   First Name: _______________

Maiden Name: _______________

Other names used___________________________________

Contact Information

Email address_______________

Home phone number _______________

Work phone number _______________

Home address:
_____________________________________________
________________________________________________
________________________________________________
________________________________________________

Please answer the following to the best of your ability:

I suspect a mold problem at:

____My place of business

____My home

____Other

If the suspected mold problem is at your home, when was the home built?______________

If you did not build your home, when did you purchase it?_______________

Please place an “X” next to any of the following warningsigns if you have noticed them at your home or place of business:

____Visible mold growth

____Discoloration or water stains on internally facing walls or ceilings

____Discoloration or water stains on externally facing walls

____Areas of standing water or condensation on floors, walls, or window sills

____Musty odor

Please place an “X” next to any of the following health effectsif you have experienced them:

____Worsening of allergies

____Respiratory problems

____Fever

____Nasal and sinus congestion

____Burning / watering eyes

____Worsening of asthma

____Coughing

____Sore throat

____Flu-like symptoms

____Skin irritation

____Headaches

Please list the name of the General Contractor who built your home (ifapplicable):
___________________________________________
___________________________________________

Any other information or concerns?
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

Next Steps

Contact a qualified personal injury attorney to make sure your rights are protected.

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