Request For Consultation

Date (mm/dd/yyyy)
First Name
Last Name
Mobile Phone # (xxx-xxx-xxxx)
Private Email Address
Home Address
City
Zip
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)
What is the current or last position you held with this employer?
If you are/were paid by the hour what is/was your hourly rate? OR If you are/were paid a salary, what is/was your annual salary?
If you are/were an hourly paid employee, do you or did you receive 1.5 times your regular rate of pay if you work(ed) over 40 hours in a week?
Do you have any concerns about how you are being paid?
If so, please explain
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?

What is your current employment status?





Have you been terminated?

If you were terminated or laid off, what was your termination date (mm/dd/yyyy)?
If you were terminated or laid off, what was the reason your employer gave you?
Please provide a brief description of what specifically has led you to contact us about your situation.
Please check all boxes that apply to your situation









If you have been offered a severance package, what is the last date for severance package to be signed (mm/dd/yyyy)?
Date you were given the Severance Agreement (mm/dd/yyyy)
Are you currently on medical leave or have you taken a medical leave during the last year of your employment?

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

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?

If you have been terminated did the Company ever offer you Severance?
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?
Are you currently taking medication for depression or anxiety?

When did you start taking this medication (mm/dd/yyyy)?
Are you currently or have you been 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 ?