Charlson Bredehoft & Cohen P.C.

Intake Questionnaire

Employment and Business Torts / Employment Contracts / Covenants Not to Compete / 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, 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 THAT YOUR EMPLOYER VIOLATED AN AGREEMENT WITH YOU ?

Yes No

If yes, which agreements did your employer violate? (please attach a copy of each if not attached above). How or why do you believe your employer violated this agreement?

8. 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 attach a copy). Why are you concerned about signing this agreement?

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

Yes No

If yes, please attach a copy if not attached before and indicate your deadline to respond.

10. DO YOU BELIEVE YOUR EMPLOYER OWES YOU ANY WAGES AND/OR BENEFITS?

Yes No

If yes, please explain what wages and/or benefits you believe your employer owes you.

11. PLEASE CHECK ANY THAT APPLY TO YOUR RELATIONSHIP EMPLOYERS:

Owner or founder
Stockholder
Stockholder of more than 5% of outstanding shares

Exempt (full time)
Non-exempt (full time)
Independent contractor
Part-time employee

12. 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.)

13. 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.

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

Yes No

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

Yes No

16. 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

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 LAWSUIT, COMPLAINT OR CLAIM BEFORE? (IF SO, PLEASE PROVIDE A DETAILED DESCRIPTION OF EACH CLAIM AND HOW IT WAS RESOLVED).

You can save a pdf copy of this form for yourself by clicking on 'Save a Copy' button. After saving a copy, please click on the 'Submit' button below to submit the form.

*Please make sure to save on a computer only if you are sure about the confidentiality of the file.



The firm's practice emphasizes civil litigation in the federal and state courts, largely in the areas of civil rights and employment litigation, and has also succesfully litigated cases ranging from battles over stock options, change in control agreements, complex employ- ment agreements, and cove- nants not to complete to torts or disputes involving medical malpractice, fraud, tortious interference with contractual relations, negligence, assault and battery, breach of contract, breach of fiduciary duty, defamation, conspiracy and intentional infliction of emo- tional distress.

	Woman wins $3.5M for ‘defamatory' evaluation

	Former executive succeeds in defamation suit

	In latest cases, high court gives, takes away



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

Potential Representation

Directions

Links

11260 Roger Bacon Drive, Suite 201 Reston, VA 20190 | Ph: 703 318 6800 | Send us an email | Web Design by Dualvision

By navigating through this site, you confirm that you have read the Terms and Conditions of this site and have understood these important notices