Charlson Bredehoft & Cohen P.C.

Intake Questionnaire

Employment Discrimination / Sexual Harassment / Retaliation / Civil Rights / Wrongful Termination / Whistleblower

NOTICE: The information contained in this questionnaire is CONFIDENTIAL and will be used by the law firm of Charlson Bredehoft & Cohen, 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, P.C. will rely on the fact that the information contained herein is truthful, accurate and complete unless noted otherwise.

1. 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)?

2. WHO IS YOUR COMPLAINT AGAINST?

Name:

Address-Street:

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

3. 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:

4. 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 attach a copy of each (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

5. HAVE YOU SIGNED ANY SEVERANCE AGREEMENT or SEPARATION PACKAGE WITH YOUR EMPLOYER? (If yes, please attach a copy.)

Yes No

6. HAVE YOU BEEN PRESENTED WITH ANY TYPE of SEVERANCE / SEPARATION AGREEMENT or PACKAGE BUT HAVE NOT YET SIGNED? (If yes, please attach a copy, along with any questions or concerns relating to the Agreement)

Yes No

7.DO YOU BELIEVE YOU WERE DISCRIMINATED AGAINST/TREATED UNFAIRLY BASED ON: (Check all that apply)

Sexual Harrasment
Race
Color
Sex
National Origin
Age
Religion
Disability

Marital Status
Sexual Orientation
Retaliation
Family Medical Leave Act
Equal Pay Act
Because I brought to the attention of my employer illegal acts
Because I refused
to engage in illegal acts
Other (Please Explain)

8. EXPLAIN WHAT ACTION WAS TAKEN AGAINST YOU THAT YOU BELIEVE WAS DISCRIMINATORY OR UNLAWFUL: (Tell us who, what, when, where and why. Feel free to attach additional sheets of paper.)

9. WHY DO YOU BELIEVE WHAT HAPPENED IS DISCRIMINATION, RETALIATION, OR OTHERWISE, ILLEGAL ? (As you marked in ¶7.)

10. WHAT REASON(S), IF ANY, WAS GIVEN FOR THE ACTION TAKEN AGAINST YOU ? (Tell us who, what, when, where and why.)

11. 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 attach a copy.

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

Yes No

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

Yes No

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 .

15. DOES YOUR EMPLOYER HAVE A GRIEVANCE/COMPLAINT POLICY/PROCEDURE THAT MAY APPLY? IF SO, PLEASE DESCRIBE AND IF POSSIBLE, ATTACH THE POLICY.

16. IF THERE IS A GRIEVANCE/COMPLAINT PROCEDURE OR POLICY, DID YOU FOLLOW IT? PLEASE DESCRIBE WHAT YOU DID. IF NOT, PLEASE EXPLAIN FULLY WHY YOU DID NOT FOLLOW IT.

Yes No

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

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

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 DISCRIMINATION SEXUAL HARASSMENT, RETAILIATION, OR WRONGFUL TERMINATION CLAIM OR COMPLAINT BEFORE? (IF SO, PLEASE PROVIDE A DETAILED DESCRIPTION OF EACH CLAIM AND HOW IT WAS RESOLVED).

23. IS THERE ANYTHING ELSE YOU BELIEVE MAY BE RELEVANT, POSITIVE OR NEGATIVE, THAT YOU BELIEVE WE SHOULD KNOW IN CONSIDERING OR EVALUATING YOUR CLAIM, OR IN REPRESENTING YOU?

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The firm's practice focuses largely in the areas of employment and business-related litigation. The firm has successfully litigated cases ranging from business-related torts such as defamation, battles over stock options, change in control agreements, complex employment agreements, and covenants not to compete, to cases such as employment discrimination, sexual harassment, retaliation, whistleblower, civil rights violations, wrongful termination, fraud, tortious interference with contractual relations, negligence, assault and battery, breach of contract, breach of fiduciary duty, conspiracy, intentional infliction of emotional distress, and less frequently, medical malpractice.

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Address: 11260 Roger Bacon Drive, Suite 201 Reston, VA 20190 Phone: 703 318 6800 Fax: 703 318 6808 Send us an email For detailed directions, please click here

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