Case Intake Form

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Case Intake Form

Begin your case by filling out an intake. A referral packet will be sent to you by the next business day.

Plaintiff or Defense *

Is this a Federal case? *

Yes

Designated Expert Requested

Fees vary depending on expertise and experience. For pricing inquiries, contact support@empowercm.com

Stella Spencer (LCP, Voc, and MBAs)

Rebecca Czarnik (LCP)

Julian Shield (Voc)

Erica Cortes (Voc)

Dr. Carlos Buckner (Physician Review, LCP Co-Author, and IMEs)

Charlene Espritt (LCP and Voc)

Dr. Melinda Sauvage (FCE)

Dr. Sahni (Neurosurgeon & Spine Surgery)

Dr. Crincoli (PM & R, Physician Life Care Plans)

Dr. Dowell (Infectious Diseases, Custom Reports)

Dr. Turner (Orthopedic Surgeon, Custom Reports)

Stephanie Birley (Life Care Plans)

Dr Jesus Aranda (Neuropsychology and Forensics)

I don't have a preference

Patient Name *

Case Caption (Parties involved)

Date of Incident *

YYYY

Patient Address (Plaintiff only)

Patient Date of Birth *

YYYY

Patient Phone Number (Plaintiff only)

Patient Email (Plaintiff only)

Services Requested *

Life Care Plan

Life Care Plan Analysis

Vocational Assessment

Vocational Assessment Analysis

Medical Cost Projection

Case Management

Functional Capacity Evaluation

Physician Case Review

Medical Bill Analysis

Required

Is this case a Florida post tort case? *

Yes

Patient Occupation *

Additional Notes

Firm Name *

Attorney Name *

Attorney Email *

Attorney Phone Number *

Paralegal Name

Paralegal Email

Billing Contact Email *

Paralegal Phone Number

Opposing Council *

Case Deadline

YYYY

Submit

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