Intake Questionnaire

Other Torts: Fraud / Defamation / Tortious Interference / Conspiracy / Conversion / Malicious Prosecution / Negligent Retention

NOTICE: The information contained in this questionnaire is CONFIDENTIAL and will be used by the law firm of Charlson Bredehoft Cohen, Brown & Nadelhaft, 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 & Nadelhaft, 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*:
Personal Email Address*:
Telephone Number* (H):
Address-Street:
County:
City:
State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyomingNon US
Zip:
Date of Birth:
Gender: MaleFemale
Race:
Telephone Number (O):
Telephone Number (Cell):
I prefer to be contacted by phone: At homeAt workBy cell phone
Best time to call:
How were you referred to/or learned of our office?:

3. WHO IS YOUR COMPLAINT AGAINST?

Name of Company/Employer:
Address-Street:
County:
City:
State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyomingNon US
Zip:
Telephone:
Type of Business:
Location(s) elsewhere: YesNo
Location where tort occurred (explain):
Company size/number of employees: Less than 1515 to 5051 to 100101 to 200201 to 500500 or more
Name(s) of Individual(s):
Address-Street:
County:
City:
State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyomingNon US
Zip:
Telephone:

4. DO YOU BELIEVE THAT THE COMPANY/INDIVIDUAL VIOLATED AN AGREEMENT WITH YOU?
YesNo

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

IF YOUR COMPLAINT IS AGAINST YOUR EMPLOYER
(Questions 5, 6, 7, 8 and 9):
5. PLEASE CHECK ANY THAT APPLY TO YOUR RELATIONSHIP WITH EMPLOYER:
Owner or founderStockholderStockholder of more than 5% of outstanding sharesExempt (full time)Non-exempt (full time)Independent contractorPart-time employee

6. EXPLAIN HOW YOU FIT INTO THE ORGANIZATION (IF APPLICABLE):
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:
7. 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).
YesNo

8. 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.
YesNo

9. 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.
YesNo

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

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

Is the policy in writing?
YesNo

If yes, can you provide us with a copy? YesNo (Explain)

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

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

14. 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.
YesNo

15. HOW, IF AT ALL, DID THE ENVIRONMENT CHANGE FOLLOWING YOUR COMPLAINT ?

16. 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:

17. 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.

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

19. 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).

I agree that the above facts are true to the best of my knowledge and belief.