Request For Consultation

Date (mm/dd/yyyy)
First Name
Last Name
Mobile Phone # (xxx-xxx-xxxx)
Alternative Phone # (xxx-xxx-xxxx)
Private Email Address
Home Address
Who Referred You to Us
Your Sex

Your Race
Your Age
Name of Employer you are contacting us about
Number of Employees
Hire Date (mm/dd/yyyy)
Current or Last Position
Are you paid by the hour or do you get paid a salary?
What is your rate of pay per hour if you are hourly paid?
What is your rate of pay per year if you are a salaried employee?
Do you receive 1.5 times your regular rate of pay if you work over 40 hours in a week?

Do you have any concerns about how you are being paid?
If so, please explain
Please check all boxes that apply to your situation

Last date for severance package to be signed (mm/dd/yyyy)
Date you were given the Severance Agreement (mm/dd/yyyy)
What is your current employment status?

Have you been terminated?

If so, termination date (mm/dd/yyyy) ?
If you were fired or laid off, what was the reason your employer gave you?
Did you receive a Separation Notice or letter of termination from the Company?

Are you currently on medical leave?

If so, when did the leave begin (mm/dd/yyyy)?
Are you currently receiving any disability pay?

If so, what type and how much?
If you believe you have been discriminated against, what makes you think this?
Did you complain of discrimination?

To whom ?

Has an EEOC Charge Been Filed?

If so, on what date (mm/dd/yyyy)?
What is the name of your EEOC investigator?
Has a Notice of Right to Sue been issued?

If so, on what date (mm/dd/yyyy)?
If so, have you gotten a copy of your complete file from the EEOC?

Please provide a brief description of what specifically has led you to contact us about your situation.
Did the Company ever offer you Severance Pay?

If yes, how much?
Did you receive the Severance Pay?

Did you ever sign a Release or other Agreement?

If yes, please provide details.
Has the Company offered you any settlement?

If yes, how much?
Do you have an Employment Contract?

Have you ever signed an Arbitration Agreement with this Employer?

Have you ever signed a Non-Compete or Non-Solicitation Agreement with this Employer?

Are you currently taking medication for depression or anxiety?

When did you start taking this medication (mm/dd/yyyy)?
Are you currently represented by another Attorney on this matter?

If so, who is the attorney? (full name and firm)
Why is s/he not representing you moving forward?
Have you filed for Bankruptcy within the past 5 years?

If yes, what date did you file (mm/dd/yyyy)?
Have you been discharged from bankruptcy?

Is there any other information that you want us to know ?