Intake Survey

Thank you for your interest in Kochan & Stephenson. If possible, please fill out the following fields. Because we are a very small firm and receive a large volume of inquiries, before we schedule an in-person meeting or phone call we want to be sure that we have the capacity and that yours is the type of claim we handle. Like many plaintiff's attorneys, we do not charge our clients on a per-hour basis, so please do not let financial concerns stop you from reaching out to us.

JotForm is a secure service that will encrypt your survey so that it cannot be accessed by anyone but us. However, we recommend that you do not complete this survey on a work computer where your browsing history may be viewed by others. Your answers should be saved within the survey, but we recommend saving any longer answers in a separate format just in case.

Click "Next" to begin.

Contact Information
Full Name *

First Name Last Name
Preferred Gender Pronouns
e.g. she/her, they/them
Personal Phone Number *

Area Code Phone Number
Personal E-mail *
Please double check to make sure the address entered is correct.
Preferred Contact Method - Note: Responses by email will be faster than responses by phone. Please only select "Phone" if you are unable to access an email account. *

Phone Email
How did you hear about us?

General Employment Information
Date of Hire
If you cannot remember the exact date, an estimation is fine.
Current Job Title *
If your employment has terminated, enter your job title before termination.
Salary/Wages
If your employment has terminated, enter your salary before termination.
Have you signed an arbitration agreement with your employer? *

Yes No Don't know
Has your employment terminated? *

Yes No
Date of Termination
Was the termination...

voluntary involuntary

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Contact Information