Employment Law Intake Form

Your Name*

Address

Home Phone

Business Phone

Cell Phone

Email*

Race

Gender

Date of Birth

Age

Who referred you to us?

Employer

Address where you worked/work

HQ/Human Resources address

Phone

Date of Hire

Last Date Worked

Date of Termination

Date of Resignation

Briefly describe your claim(s)

Are you represented by a union? If so, which?

Have you filed a grievance regarding the issue you are raising with this firm?
If yes, please describe the grievance and what has happened with it so far.

Have you received treatment from a health care professional regarding the issue you are raising with this firm? If yes, please provide the name of the practitioner, area of practice, address, dates of treatment, diagnosis if known and the treatment provided, e.g. medication prescribed. Have you had any history of similar health issues prior to the issue you are raising with this firm?

Have you ever been terminated from a job prior to the issue you are raising with this firm?
If yes, state the employer name and the year of the termination.

Have you ever filed for bankruptcy? If yes, what kind and when?
Is the estate closed / bankruptcy discharged? Who represented you in the bankruptcy proceedings?

Have you ever been involved in a lawsuit before? If yes, provide details below.

Have you ever been charged with or convicted of a crime? If yes, provide details below.

You should understand that if we file a lawsuit on you behalf, your background will be extensively investigated by the other side. Is there anything we should know about your history prior to agreeing to represent you? Is there anything that would be damaging or embarrassing that may be revealed?