SA-05 Nationwide Sexual Abuse | Maas Attorney Intake

1Center information

Center Code

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Agent Name

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TF Link (TrustedForm certificate URL)

Paste the TrustedForm certificate link (https://cert.trustedform.com/…)

Call type

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Lead source / publisher (optional)

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2Qualification

Are you currently represented by an attorney for this matter?

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DQ: Represented by attorney

Have you spoken to or signed with another law firm about this before?

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Have you already settled or signed a release for this injury?

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DQ: Already settled / released

Have you been convicted of a felony?

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Have you filed for bankruptcy since the injury / diagnosis?

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3Client information

Client First Name

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Middle Name

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Client Last Name

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Suffix

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Gender

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Birthdate

Valid birthdate required (18+)

Marital status

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Client Street (Primary)

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Apt / Unit

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Client City (Primary)

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Client State (Primary)

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Client Zip Code (Primary)

5-digit ZIP

Client Phone (Primary) (10 Digit Number Only - No Hyphens or Parenthesis)

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Alternate Phone

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Client Email (Primary)

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Best time to call

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Preferred language

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4Injured person

Is the client the injured person?

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Injured person's full name

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Injured person's date of birth

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Client's relationship to the injured person

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Date of death

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Cause of death (per death certificate)

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Is the client the executor / estate representative?

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5Medical & insurance

Main treating doctor / hospital (name & city)

Required

Primary care doctor (name & city)

Required

Pharmacy used (name & city)

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6SA-05 · Nationwide Sexual Abuse questions

State where the abuse happened

Required

Survivor's age when it happened

Required

Survivor's age today

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Year(s) it happened

Required

Where / in what setting?

Required

Organization involved (if any)

Required

Abuser's role / relationship

Required

Type of abuse

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Has a lawsuit or claim already been filed for this abuse?

Required

DQ: Claim already filed

7Case summary & documents

Case summary – what happened, in the client's own words

Required

Upload documents (optional – attach anything the client has already sent)📎 Click to attach documents or drag files herePDF, photos (JPG / PNG / HEIC), Word · up to 10 files · 10 MB each

Check the files: max 10 files, 10 MB each

Agent notes (internal)

Required

SA-05 Nationwide Sexual Abuse Intake

1Center information

2Qualification

3Client information

4Injured person

5Medical & insurance

6SA-05 · Nationwide Sexual Abuse questions

7Case summary & documents

Submitted