Intake Questionnaire

Employment and Business Torts / Change in Control / Stock Option Disputes / Miscellaneous Employment-Related Disputes

NOTICE: The information contained in this questionnaire is CONFIDENTIAL and will be used by the law firm of Charlson Bredehoft Cohen & Brown, P.C. to assist in determining whether the firm can help you with your case. No attorney-client relationship is established by the provision of confidential information, and no attorney-client relationship will be established until such time as you and we sign a written agreement establishing an attorney-client relationship. It is understood that the law firm of Charlson Bredehoft Cohen & Brown, P.C. will rely on the fact that the information contained herein is truthful, accurate and complete unless noted otherwise.

1. IS THERE A KNOWN DEADLINE THAT YOU ARE FACING? (Explain)

2. INFORMATION

Date:

First Name:

Middle Name:

Last Name:

Address-Street:

County:

City:

State:

Zip:

Home Email Address:

Date of Birth:

Gender:

Male Female

Race:

Telephone Number(H):

Telephone Number(O):

Telephone Number(Cell):

I prefer to be contacted by phone:

At home At work By cell phone

Best time to call:

How were you referred to/or learned of our office?

To which attorney in our office were you referred (if any)?

3. WHO IS YOUR COMPLAINT AGAINST?

Name of Company/Employer:

Address-Street where you work(ed):

County:

City:

State:

Zip:

Telephone:

Type of Business:

Location(s) elsewhere:

Yes No

Address:

Company size/number of employees:

Less than 15
15 to 50
51 to 100

101 to 200
201 to 500
500 or more

Name(s) of Individual(s):

Address-Street:

County:

City:

State:

Zip:

Telephone:

4. EXPLAIN HOW YOU FIT INTO THE ORGANIZATION

Your date of hire:

Your date of demotion or termination (if applicable):

Department/Division you work(ed) in:

Your position title:

Date you were assigned to this position:

Your wage/salary:

Benefits:

Your immediate supervisor's name:

Your immediate supervisor position's title:

5. Do you have an Employment Agreement, Stock Option, Covenant Not to Compete, Non- Solicitation Agreement, or any other agreement or contract with your Employer? If yes, please contact us for instructions as to how to submit a copy (unless they do not relate, but please indicate the name or description and date of each so we are aware of its existence).

Yes No

6. Have you signed any Severance Agreement or Separation Package with your employer? ( If yes, please contact us for instructions as to how to submit a copy.)

Yes No

7. Have you been presented with any type of Severance/Separation Agreement or Package but have not yet signed? ( If yes, please contact us for instructions as to how to submit a copy, along with any questions or concerns relating to the Agreement.)

Yes No

8. What specific questions or concerns do you have regarding the Agreement?

9. DO YOU BELIEVE THAT YOUR EMPLOYER VIOLATED AN AGREEMENT WITH YOU ?

Yes No

If yes, which agreements did your employer violate? (please contact us for instructions as to how to submit a copy). How or why do you believe your employer violated this agreement?

10. ARE YOU CONCERNED ABOUT AN AGREEMENT YOUR EMPLOYER WANTS YOU TO SIGN ?

Yes No

If yes, which agreement does your employer want you to sign? (Please contact us for instructions as to how to submit a copy). Why are you concerned about signing this agreement?

11. HAS YOUR EMPLOYER OFFERED YOU A SEVERANCE AGREEMENT AND/OR PACKAGE THAT YOU ARE CONSIDERING?

Yes No

If yes, please contact us for instructions as to how to submit a copy and indicate your deadline to respond.

12. PLEASE CHECK ANY THAT APPLY TO YOUR RELATIONSHIP WITH YOUR EMPLOYER:

Owner or founder
Stockholder
Stockholder of more than 5% of outstanding shares
Exempt (full time)
Non-exempt (full time)
Independent contractor
Part-time employee

13. IF YOU HAVE ANY OTHER ISSUE WITH YOUR EMPLOYER, NOT ALREADY COVERED IN THIS QUESTIONNAIRE, PLEASE EXPLAIN THE SITUATION HERE ? (Tell us who, what, when, where, and why.)

14. WHAT IS THE EMPLOYER'S NORMAL POLICY/PRACTICE IN A SITUATION SUCH AS YOURS, IF APPLICABLE ?

Is the policy in writing? Yes No

If yes, can you provide us with a copy? Yes No (Explain)

If yes, please contact us for instructions as to how to submit a copy.

15. HAS THE SAME THING HAPPENED TO OTHERS ? (If yes, please tell us who, what, when, where and why.)

Yes No

16. HAVE OTHERS BEEN TREATED DIFFERENTLY THAN YOU ? (If yes, please tell us who, what, when, where and why.)

Yes No

17. DID YOU REPORT THE ACTION TO ANYONE AND, IF SO, TO WHOM AND WHEN? PLEASE ALSO DESCRIBE WHAT INVESTIGATION, IF ANY, AND WHAT ACTION, IF ANY, WAS TAKEN AS A RESULT OF YOUR COMPLAINT.

Yes No

18. HOW, IF AT ALL, DID YOUR WORK ENVIRONMENT OR TERMS OF EMPLOYMENT CHANGE FOLLOWING YOUR COMPLAINT ?

19. DO YOU HAVE ANY WITNESSES ? (We will not contact anyone until we have spoken to you and obtained your consent.)

Witness 1 /Name:

Witness 1 / Relevant Relationship:

Witness 1 / Telephone No - Email Address:

Witness 2 /Name:

Witness 2 / Relevant Relationship:

Witness 2 / Telephone No - Email Address:

Witness 3 /Name:

Witness 3 / Relevant Relationship:

Witness 3 / Telephone No - Email Address:

20. IF YOU WERE TERMINATED, HAVE YOU BECOME RE-EMPLOYED? IF SO, HOW MUCH MORE OR LESS ARE YOU EARNING TODAY IN RELATIONSHIP TO WHAT YOU EARNED AT THE POINT OF TERMINATION ? Please include a detailed and itemized comparison of salary, commissions, bonuses, and all benefits between your previous position (that from which you were terminated, etc.) and your new position.

21. HOW DID THESE EVENTS IMPACT YOU, AND DO THEY CONTINUE TO AFFECT YOU TODAY?

22. HAVE YOU EVER FILED ANY TYPE OF LAWSUIT, COMPLAINT OR CLAIM BEFORE? (IF SO, PLEASE PROVIDE A DETAILED DESCRIPTION OF EACH CLAIM AND HOW IT WAS RESOLVED).

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Intake Questionnaire

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