Occupational Assessment Services, Inc.
16850 Collins Avenue #112344
Sunny Isles Beach, FL 33160
1-973-365-2227
Case Flow Sheet- General Intake Form
Attorney must provide translator for non-English speaking evaluees to assist in completion of all forms.
Hiring Attorney Information
Contact information
Prefix
First name
*
Middle name
Last name
*
Company
Emails
Address
*
Type
Upon submission, a copy of this form will be sent to the primary email.
Work
Home
Other
Primary
Default email false
Add email
Addresses
Street address
Country
Australia
Canada
United Kingdom
United States
---------------
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
City
State/Region
Alaska
Alabama
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
United States Minor Outlying Islands
Utah
Virginia
Virgin Islands, U.S.
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Province/Region
Zip/Postal code
Address type
Work
Billing
Home
Other
Primary
Default address false
Add address
Phone numbers
Phone number
Type
Work
Home
Mobile
Fax
Pager
Skype
Other
Primary
Add phone number
* MUST ADD Lead Attorney's first/last name, email address and telephone number.
Defendant:
Defense Firm & Attorney
Insurance Carrier contact:
Client/ Evaluee Information
Full name of the Client or Evaluee, and indicate whether they are the Plaintiff or Defendant.
Client/Evaluee Gender
Date of Birth:
Client E-mail address
Client Phone Number
Client address
County where client lives
Is your client experienced with Zoom / Video Conferencing software?
Yes
No
Not sure
Report Processing Options
Report Submission Deadline
Standard: 6-10 weeks from date of evaluation.
Rush: 4-6 weeks from date of evaluation.
Select an Option
Standard Time
Rush Report
Important Deadlines
Report Due Date (Only If Rush Selected)
Is there a discovery deadline?
Is there a trial date?
Case Documentation
Is there an opposing report?
Is there a vocational report?
Is there an existing life care plan on this case?
Is there a home health aid, LPN and/or RN for care?
Yes
How many hours of care is needed?
No
Translator Services
Translator Services ( If needed MUST provide CERTIFIED translator)
No, a translator is not required
Yes, I will be providing a CERTIFIED translator (Must be provided by attorney or client)
Language
Case Details
Type of Service:
Select an Option
Vocational Evaluation
Life Care Plan
Modified Life Care Plan
Wrongful Death
Type of Case:
Select an Option
Personal Injury
Other
Medical Malpractice
Matrimonial
Workers' Compensation
Social Security
Wrongful Termination
Wrongful Death
Veterans/TDIU
Defense
Pick:
Plaintiff
*PLEASE STATE IF YOUR CASE IS PLAINTIFF OR DEFENSE*
Defendant
*PLEASE STATE IF YOUR CASE IS PLAINTIFF OR DEFENSE*
Pick:
Federal
State
County of Court Case
Additional Services
Add Loss of Household Services Evaluation (+$1500) Only applies to Plaintiff VOC (HHS included MLCP and LCP)
Yes
No
Are You working with an economist?
Yes
No
Evaluation Process
Manner of Evaluation:
Select an Option
Facetime / Skype / Zoom
Attorney's Office
Additional Appointment Requests:
Injury Notes (if applicable):
Who will be your expert physician(s)?
Additional Information & Contacts
Any additional information you think would be helpful (ex: other representing party contact info):
Name and email for who should receive zoom link prior to evaluation:
Name and email of who should receive client forms:
Contact phone number of the person we are evaluating in case of any technical difficulties:
How did you hear of us?
We're curious to know your journey to OAS. Are you a valued returning client, or were you recommended by a fellow client? Your insights are important to us.
THANK YOU
If you have completed the form, please click
SUBMIT
.