Client Intake Questionnaire Old

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Personal Information Name

Address

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Home Telephone Number

Mobile Telephone Number

Work Telephone Number

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E-mail Address

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May we contact you by email?

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Are you currently employed?

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If so, where?

FALSE CLAIMS ACT � the False Claims Act and similar statutes generally allow a person to bring a lawsuit on behalf of the government whom they believe has been defrauded by the defendant. If you believe that you may have a case under the False Claims Act, or a whistleblower statute, please provide the following information: (If you case involves Excessive Force, or you are charged with a crime please go to question #x).

How Can We Help You? Company that you believe is involved in committing fraud:

Location of Company:

Describe the general nature of the action which you believe caused false claims to be submitted to a government:

Do you have any documents that support your allegations?

Yes No

Do you have any document that show that the defendant submitted a false claim to the government?

Yes No
If there are documents that would support your claim, where are those documents located?

Have other attorneys worked on this matter?

Yes No
Who engaged in or directed this fraud

When did you first learn of the fraud

When did the fraud begin

When did the fraud end

Have you reported you allegations/concerns to anyone including the company, government, law enforcement, or the media?

Yes No

Do you still work for this company?

If you no longer work for this company were you fired? If so, explain.

Did you file a wrongful termination case or claim? If so, provide the case name, number, Court in which the case was filed and the case status.

Have you ever filed any lawsuit before? If so, what was the nature of the case?

How much money do you believe was paid by the government because of the fraud? Please explain and include a time period.

EXCESSIVE FORCE When did the act of excessive force happen?

Describe what generally occurred:

Who do you believe would be the defendants in this case?

Describe your injuries:

Did you go to a hospital or seek medical care?

Yes No

Are you still suffering or seeking medical care because of the excessive force?

Where you arrested? If so, what were you charged with a crime and what is the status of the case?

Are there any witnesses? If so who?

CRIMINAL DEFENSE When were you arrested?

What police department arrested you?

What are you charged with?

What are the police saying you did?

Have you been to Court yet? If so, when and for what (bond hearing, arraignment, preliminary hearing)?

When is your next court date, where, and at what time?

What is the status of your case?

Are you currently represented by an attorney? If so, is it a public defender or a private attorney?

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

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E-mail Address Please enter a valid e-mail address.

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Brief description of your legal issue

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Articles

Rosenblat & Associates, Ltd.
707 Skokie Boulevard , Suite 600
Northbrook, Illinois 60062
Phone: 312-957-5816
Toll Free: 888-833-1428
Fax: 312-551-0322
Northbrook Law Office

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Rosenblat & Associates, LTD, serves the Chicago, Illinois area including Evergreen Park, Burbank, Oak Lawn, Hickory Hill, Palos Hills, Lemont, Bolingbrook, Naperville, La Grange, Wheaton, Elmhurst, Lombard, Elk Grove, Des Plaines, Niles, Morton Grove, Skokie, Glenview, Northbrook, Arlington Heights, Schaumburg, Elgin, Cook County, Lake County, McHenry County, DuPage County, Kane County, Kendall County, Grundy County, Will County and Kankakee County.