CONFIDENTIAL INTAKE QUESTIONNAIRE (cont’d)

Confidential Intake Questionnaire

Please complete all questions to the best of your ability.

The purpose of this questionnaire is to obtain basic information about your employment why you contacted an attorney.

INFORMATION ABOUT YOU

  1. Name: Click here to enter text.Male ☐ Female ☐
  2. Home Address Click here to enter text.
  3. Phone numbers (check preferred number)

☐ Home: Click here to enter text.

☐ Cell: Click here to enter text.

☐ Current Work: Click here to enter text. May we call you here? ☐ (Y) ☐(N)

  1. Personal e-mail address:Click here to enter text.
  2. Date of birth: Click here to enter text. Current Age: Click here to enter text.
  3. Race:Choose an item.Additional description: Click here to enter text.
  4. National Origin: Choose an item. Additional description: Click here to enter text.
  5. Who referred you to our office?Click here to enter text.

INFORMATION ABOUT YOUR EMPLOYMENT MATTER

  1. Name of employer: Click here to enter text.
  2. Address of location where you worked: Click here to enter text.
  3. What are your dates of employment?Click here to enter text.

If no longer employed, when was your last day of work?Click here to enter text.

  1. How many employees (total) work for the employer? Click here to enter text.

How many employees work at your location?Click here to enter text.

  1. What is the nature of your employer’s business?Click here to enter text.
  2. What is/was your job title? Click here to enter text.
  3. Please describe your duties as specifically as possible: Click here to enter text.
  4. Who is/was your direct supervisor? Click here to enter text.

Please describe your supervisor’s title and job duties. Click here to enter text.

  1. What is/was your method of compensation? Choose an item.

What is/was your last hourly rate or annual salary?Click here to enter text.

Are you paid overtime for hours worked over 40/week?☐ (Y) ☐ (N)

Other comments regarding compensation?Click here to enter text.

  1. Does your employer have handbooks/policies applicable to your case? ☐ (Y) ☐ (N)

If “yes,” please describe & provide. Click here to enter text.

  1. If you no longer work for the employer:
  2. Why? Choose one: Choose an item.

Additional description: Click here to enter text.

  1. On what date?Click here to enter a date.
  2. If you were terminated or laid off, what is your employer’s stated reason for the termination/layoff? Click here to enter text.
  3. If different, what do you believe the actual reason is (note, you will also be asked to elaborate in #12-13 below)? Click here to enter text.
  4. Are you currently employed elsewhere? ☐ (Y) ☐ (N)

If so, please state the date your new employment started, your new employer’s name, your new title, and your new compensation: Click here to enter text.

  1. Check all that apply:

☐I need to negotiate an employment agreement, severance agreement, or some other type of contract.

☐I have not been paid wages (includes unpaid regular pay, unpaid overtime, unpaid vacation days, etc.).

☐I have been discriminated against or harassed, based upon:

☐ Race ☐ Gender ☐ Age ☐ Sexual Orientation ☐ Disability ☐ Religion

☐ National Origin ☐ Military Status ☐ Other

☐ I have been subject to retaliation.

☐ I am having a problem receiving employee benefits, including pension/retirement plan or COBRA.

☐ I am having a problem with my sick days or with Family and Medical Leave.

☐ I am being threatened with a lawsuit or am being sued by my employer or former employer.

☐ I am having Union problems.

  1. If you checked any of the boxes in #12 above, please describe in your own words why you are seeking legal advice: Click here to enter text.
  2. Are other employees experiencing the same treatment? ☐ (Y) ☐ (N)

If “yes,” please describe.Click here to enter text.

ACTIONS ALREADY TAKEN

1.Have you consulted with another lawyer before seeing us? ☐ (Y) ☐ (N)

If so, who?Click here to enter text.

2.Are you/were you in a Union? ☐ (Y) ☐ (N)

If so, did you file a grievance? ☐ (Y) ☐ (N)

Please provide Union contact information. Click here to enter text.

3.Have you filed a charge with any governmental administrative agency? ☐ (Y) ☐ (N)

  1. Please check all that apply, and indicate the date of your charge:

☐ Equal Employment Opportunities Commission: Click here to enter a date.

☐ Illinois Department of Human Rights: Click here to enter a date.

☐ Illinois Department of Labor: Click here to enter a date.

☐ Department of Fair Employment & Housing: Click here to enter a date.

☐ Division of Labor Standards Enforcement: Click here to enter a date.

  1. Have you received a determination and/or a Right to Sue letter? ☐ (Y) ☐ (N)

If “yes,” when? Click here to enter text.

If “no,” what is the status of the charge? Click here to enter text.

Additional comments: Click here to enter text.

4.Have you made a monetary demand to try to resolve this issue? ☐ (Y) ☐ (N)

If “yes,” what was your demand? Click here to enter text.

5.Has the company offered you a money settlement to resolve this issue? ☐ (Y) ☐ (N)

If “yes,” how much?

6.Have you already made any attempts to negotiate your matter directly with the employer? ☐ (Y) ☐ (N)

If so, please describe. What was the outcome?Click here to enter text.

OTHER IMPORTANT INFORMATION AFFECTING YOUR MATTER

  1. Do you have witnesses who can corroborate your claim? ☐ (Y) ☐ (N)

Who are they, and what do you believe they know?Click here to enter text.

  1. Have you ever received any verbal or written discipline? ☐ (Y) ☐ (N)

Please describe. Click here to enter text.

Do you have copies? ☐ (Y) ☐ (N)

  1. Do any written evaluations of your work exist? ☐ (Y) ☐ (N)

Were the evaluations favorable? ☐ (Y) ☐ (N)

Do you have copies? ☐ (Y) ☐ (N)

  1. What result are you looking for? Please check all that may apply:

☐ Reinstatement

☐ Promotion

☐ Negotiate separation package

☐ Help with filing administrative action (EEOC, IDHR, IDOL, DFEH, DSLE, etc.)

☐ File lawsuit

☐ OtherPlease describe: Click here to enter text.

  1. What do you believe the value of your claim(s) may be? Click here to enter text.

What is the basis for your calculation of that value?Click here to enter text.

  1. Have you ever filed a lawsuit in the past? ☐ (Y) ☐ (N)

If “yes,” please describe when and why:Click here to enter text.

  1. Please describe any problems with your case(i.e., how would the employer respond to your claims if you brought a lawsuit against it):Click here to enter text.
  2. Are you aware of any deceptive practices or fraud at the company such as fraudulent billing or accounting? ☐ (Y) ☐ (N)

If “yes,” please describe. Click here to enter text.

  1. Are you active on social media? ☐ (Y) ☐ (N)

Please check all that apply:

☐ Facebook ☐ LinkedIn ☐ Twitter ☐ Blogging/vlogging

☐ OtherPlease describe: Click here to enter text.

  1. Have you ever been arrested or convicted of a crime? ☐(Y) ☐ (N)

If “yes,” please describe:Click here to enter text.

  1. Have you ever filed/are you currently thinking of filing for bankruptcy? ☐ (Y) ☐(N)

If “yes,” please describe:Click here to enter text.

  1. We are happy to make referrals, when requested. Is there any other legal matter for which you need a referral to another attorney?☐ (Y) ☐ (N)

If “yes,” please describe: Click here to enter text.

This questionnaire is true and completed to the best of my ability☐ (Y) ☐ (N)

Electronic Signature: Click here to enter text.

Date:Click here to enter a date.

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