Your Name (required)

Zip code

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Your Phone

Identify the employer or company with which you have a legal problem:

Approximately how many employees does this company have?:

Job title:

What was/is your salary with this company?:

Briefly describe your legal problem:

If you were terminated, were you offered any severance?:
yesno

If so, how much?:

Have you signed a waiver or release of legal claims?:
yesno

All communications between you and Cole|Reichek, PLLC, including this questionnaire, are privileged, which means that they will be kept in the strictest confidence by the firm. Please note, however, that Cole|Reichek, PLLC’s provision and review of legal advice or any agreement to represent you. No attorney-client relationship will be formed unless and until a Legal Services Agreement is executed between you and Cole|Reichek, PLLC. This questionnaire will be destroyed if Cole|Reichek, PLLC does not represent you.
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