Individual Client Questionnaire | Empower Development Group

Step one

Contact Information and Preferences

* Required field

Full legal name * Preferred name Email address * Phone number * City and state * State where the work occurred * Safest time to contact you

Are you 13 years of age or older? *

YesNo

Preferred contact method *

EmailText messagePhone call

May EDG leave a voicemail?

YesNo

May EDG text you for scheduling and service-related communication?

YesNo

Step two

Employment and Professional Background

Current or former employer *Industry Job titleDepartment Employment start dateLast day or separation date

Work arrangement

On-siteHybridRemoteNot applicable

Worker classification

EmployeeIndependent contractorUnsure

Are you represented by a union?

YesNoUnsureNot applicable

Step three

Support Requested

Select every area in which you may need guidance or support.

Briefly describe what happened. * What outcome or support would you like from EDG? *

Step four

Timeline and Deadlines

When did the concern begin?Date of most recent eventResponse due dateHearing, meeting or interview dateAgency filing deadlineDesired consultation date

Is there an immediate deadline or risk? *

YesNoUnsureNot applicable

Explain any urgent deadline, scheduled proceeding, safety concern, or immediate decision.

Step five

Steps Already Taken

Describe reports, meetings, complaints, grievances or appeals already made and the response received.

Have you signed a write-up, agreement, severance, release, resignation, settlement, or other related document?

YesNoUnsureNot applicable

If yes, identify the document and the date signed.

Step six

People and Events

List key people by name or role and briefly describe their involvement. * List the most important events in chronological order. Include approximate dates when exact dates are unknown. *

Are there witnesses or others who experienced similar conduct?

YesNoUnsureNot applicable

If yes, identify them by name or role and explain what they may know.

Step seven

Documents and Evidence

Identify the most important documents and whether they are available to share securely if requested.

Please do not upload or transmit confidential records yet. EDG will advise you if and how documents should be provided after reviewing your inquiry.

Step eight

Consultation and Service Preferences

Preferred meeting formatGeneral availabilityPreferred service timingHow did you hear about EDG?

Is there anything else EDG should know before contacting you?

Step nine

Acknowledgment

EDG provides human resources consulting, professional mentorship, document and correspondence support, and workplace-process guidance. EDG is not a law firm, does not provide legal advice or attorney representation, and does not guarantee an outcome. Submitting this form does not create a consulting relationship.

Please confirm each statement *

The information is accurate to the best of my knowledge.I understand EDG may request clarification or supporting documents.I authorize EDG to contact me about this inquiry.I understand legal, contractual, agency and hearing deadlines remain my responsibility.I understand EDG does not provide legal advice or attorney representation.I have reviewed the EDG Privacy Policy.

Typed name as acknowledgment *

Final review

Review Your Responses

Please review your information before submitting. Use Back to make corrections.