Client Intake – Short Form | Kuchinsky Law Office

Please fill out this Employment Law questionnaire as much as you can so we can evaluate your case.

Your Current Address*

City State ZIP Code

Your Name*

First Last

Your Email*

Your Phone Number

Consent

I agree.

By providing my phone number to “KUCHINSKY LAW OFFICE, P.C.”, I agree and acknowledge that “KUCHINSKY LAW OFFICE, P.C.” may send text messages to my wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP”. For more information on how your data will be handled please see our privacy policy below:

PRIVACY POLICY:
No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

Your Age*

Identify the employer with whom you have a problem.*

State the employer's physical address where you worked.*

How large is the employer?*

1-5 employees
6-50 employees
More than 50 employees

When did you start working for the employer?*

When was your actual last day of work?*

Describe your job duties.*

Describe your compensation structure.*

What was your hourly rate during the last pay period?

What is your annual gross compensation?

Less than $50,000
$50,000 - $100,000
More than $100,000

What was your classification?*

I was classified as an employee and employment taxes were deducted from my paycheck.
I was classified as an independent contractor and received a 1099 form.
I was classified as an employee and independent contractor.
Not sure.

Are you a member of a union?*

Yes, I am a member of a union.
No.
Not sure.

Please tell us why you are looking for an employment attorney and any additional information that may help us to evaluate your case.*

Consent*

I agree to the below terms.

By submitting this form you acknowledge and understand that the use of this form in no way creates an attorney-client relationship with Kuchinsky Law Office, PC or Alexei Kuchinsky. An attorney-client relationship will only come into being between you and Kuchinsky Law Office, PC only if you and Kuchinsky Law Office, PC enter into a written fee agreement that is prepared by Kuchinsky Law Office, PC. If you have any questions regarding this disclaimer please contact our office at (628) 200-0902.

Name

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Client Intake Short Form

Please fill out this Employment Law questionnaire as much as you can so we can evaluate your case.