Intake Questionnaire: CONFIDENTIAL: ATTORNEY-CLIENT PRIVILEGED DOCUMENT

In order for us to have a better understanding of the issues you are inquiring about, and whether or not we will be able to be of help to you, we would appreciate your filling out the questionnaire below and returning it to us according to the instructions below.

We will get back to you within 2 to 3 days of our receipt of your questionnaire. If your situation is truly an "emergency", please call (856) 914-9200 and let our office manager, Craig, know, and we will do our best to get back to you immediately.

Important Notices: By asking you to fill out and send in this Questionnaire, the law firm of Schall & Barasch is NOT agreeing to take any legal action on your behalf or to represent you in any way. Any agreement by this law firm to take any legal action for you must be agreed to in writing and signed by one of the attorneys at this firm. This document is NOT such an agreement.

Please be advised that in the event an initial consultation is scheduled with you, the fee for that consultation is $350 per hour, which is payable at the time of the consultation.

1. Your Name (Last Name, First Name)

2. Today's Date (MM/DD/YY)

3. Street Address

City:    State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip Code:

4. Home Telephone:

5. Work Telephone:
(Only if we can call you there)

6. Cell Phone:

7. Home E-mail Address:

8. Best Time to Call:

9. Name of Company/Organization for Which You Worked, or Still Work.

10. Street Address of Company:

Company City:   Company State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

11. What Was Your Date of Hire at this Company (MM/DD/YYYY)

12. How Old Are You, and What is Your Date of Birth: (MM/DD/YY)
Age:   D.O.B.

13. Job Title/Description

14. Your Salary or Hourly Rate of Pay

15. Briefly Describe For Us How You Feel Your Employment Rights Were Violated, or Describe the Issue About Which You Are Presently Concerned:

16. When (on what date) did these events (described above) happen?

17. Do you think you might have been discriminated against because of your Age? Sex? Sexual Orientation? Disability or History of Disability? Race? National Origin? Taking Family and Medical Leave Act (FMLA) Leave? Whistleblowing? Other Factor? If yes, please explain why:

18. Do you feel that your company violated the terms of the company’s employee
handbook? If so, tell us what provision of the handbook you feel was violated?

19. Is there any other information that may help us understand why you feel your rights were violated by your employer?

20. Can You Tell Us How You Feel You’ve Been Damaged By the Action Your Employer has Taken Against You?

 21: How did you hear of Schall & Barasch? Please be specific:

*Important Notice: By asking you to fill out and send in this Questionnaire, the law firm of Schall & Barasch is NOT agreeing to take any legal action on your behalf or to represent you in any way.

Any agreement by this law firm to take any legal action for you must be agreed to in writing and signed by one of the attorneys at this firm. This document is NOT such an agreement.