Intake Questionaire | Enhance Your Work Experience — Get Support Now

Section 01

About You

Basic contact information so we can reach you. Nothing here goes to your employer.

First Name *

Last Name *

Email Address *

Phone Number Optional — for your clarification call

Preferred Name If different from above

Section 02

Your Workplace

Help us understand the environment we'll be negotiating in. The more context you provide, the better prepared we are.

Employer Name *

Your Job Title *

Time in Role *

Approximate Company Size *

Work Setting *

Industry

Does your employer have an HR department? *

Yes, a dedicated HR department Yes, but HR is handled by one person or a small team No formal HR — managed by ownership or management directly I'm not sure

Section 03

Your Limitations at Work

You do not need to share your diagnosis. We only need to understand how your condition affects your ability to perform your work. Describe your experience, not your medical chart.

Describe how these limitations affect your day-to-day work * Be as specific as you can. For example: "I cannot reliably be in the office before 10am due to morning symptom severity" or "I need to rest for 20 minutes after meetings."

Do you have documentation from a healthcare provider supporting your limitations?

Yes, I have documentation I can provide Yes, but I would need to request it from my provider No, I don't have documentation I'm not sure what I have

Section 04

What You Are Asking For

Tell us what accommodations would allow you to perform your job effectively. Be specific where you can — the more precise your request, the stronger our negotiating position.

Describe your accommodation request in your own words * Include any specifics that aren't captured above. For example: "I need to work from home on Tuesdays and Thursdays" or "I need a 30-minute break after every 2 hours of screen time."

If you could only get one accommodation, which would matter most? This helps us prioritize if the employer pushes back.

Section 05

Your Employer Relationship

This helps us understand the negotiating environment and anticipate any friction points before we make contact.

Have you raised any accommodation needs with your employer before? *

No, I have not raised this before Yes, informally — I mentioned something but didn't make a formal request Yes, formally — I made a request and it was granted Yes, formally — I made a request and it was denied or ignored

If you've raised this before, what happened? Leave blank if this is your first request.

How would you describe your current relationship with your direct manager? *

Does anyone at your workplace already know about your health situation?

My direct manager knows HR is aware Colleagues know Nobody at work knows

Is there anything about your employment situation we should know before we make contact? For example: active performance review, recent disciplinary action, upcoming leave, recent management change.

Section 06

Your Concerns

We want to know what worries you most going into this. The more we understand your concerns, the more carefully we can protect against them.

What concerns you most about this process? * Check all that apply

Retaliation from my employer My diagnosis being disclosed Being seen as a difficult employee The request being denied Impact on my relationship with my manager Job security Not knowing my legal rights The process taking too long Other

Is there anything else you want us to know before we begin?

Section 07

Service Fee

Select the salary band that reflects your current annual compensation. Your fee is determined by this band. A $50 deposit is collected at submission and applied toward your total.

Your current annual salary * A recent paystub will be required to verify your salary band before your engagement begins.

Under $35,000 $100 total · $50 due today $35,000 – $55,000 $175 total · $50 due today $55,000 – $80,000 $300 total · $50 due today $80,000 – $120,000 $450 total · $50 due today $120,000 – $175,000 $650 total · $50 due today $175,000 and above $900 total · $50 due today