AKGLLP Confidential Intake Questionnaire

Confidential Intake Questionnaire

If you would like AK+G to review your situation, please complete and submit this questionnaire.
We will be in touch promptly.

Instructions: Complete all blanks on this form and submit your completed form to our office via fax, e-mail, or first class mail.

First, Middle, and Last Name: (required)

Street Address (Include Apartment No. if applicable):

City/State/Zip Code:

Home Phone:

Cell Phone (required):

E-mail (required):

Date of Birth:

Sex (Choose One):


Who referred you to AKG?

To which attorney at AKG were you referred?

If you were not referred to a specific attorney, with which attorney would you like to speak?

Name of Employer(s):

Number of Employees at Employer(s):

When were you hired?

Your Job Title:

Most Recent Salary or Hourly Wage:

If you are a union member, what union?

What harm (fired, laid off, demoted, reassigned or transferred unfairly, not promoted, not accommodated, reasonable request denied, etc.) was inflicted on you?

On what date(s) was this harm inflicted on you?

What reason(s) did the employer give for taking the action(s) that it took?

Do you believe this is the true reason why your employer took the action(s) you are complaining about?

If not, what is the true reason(s) why your employer took the action(s) you are complaining about?

Did you resign? (Choose One):

If yes, when did you resign (date, including year)?

Did you ever complain to your employer about the harmful actions against you (either orally or in writing)? If yes, on what date(s) and to whom did you complain?

Explain why you are contacting AKG for possible representation by providing a summary of the reasons why you believe you were treated wrongfully by your employer:

Have you ever taken a leave of absence from work? If so, on what dates and for what reasons:

Do you believe you were fired or harmed in some other way for taking a leave of absence?

Have you ever filed a workers' compensation claim? If so, when (dates)?

If there is any other information that you wish to provide for AK+G to assess your situation (including offers of severance or settlement), please provide below:

Note: Although the information you provide to us on this form is confidential, completion and/or submission of this form to us does not create an attorney-client relationship between Alexander Krakow + Glick LLP ("AK+G") and you.  No attorney-client relationship shall exist until AK+G and you make a mutual decision to work together and make a written agreement stating the specific terms of that attorney-client relationship.  While this questionnaire does not create an attorney client relationship, your information will be confidential and privileged. We will not disclose your information and you may not be compelled to disclose your communications with us to anyone.