Request For Consultation
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Date (mm/dd/yyyy)
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First Name
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Last Name
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Mobile Phone # (xxx-xxx-xxxx)
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Alternative Phone # (xxx-xxx-xxxx)
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Private Email Address
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Home Address
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City
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Zip
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Who Referred You to Us
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Your Sex
Male
Female
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Your Race
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Your Age
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Name of Employer you are contacting us about
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Number of Employees
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Hire Date (mm/dd/yyyy)
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Current or Last Position
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Are you paid by the hour or do you get paid a salary?
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What is your rate of pay per hour if you are hourly paid?
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What is your rate of pay per year if you are a salaried employee?
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Do you receive 1.5 times your regular rate of pay if you work over 40 hours in a week?
Yes
No
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Do you have any concerns about how you are being paid?
Yes
No
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If so, please explain
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Please check all boxes that apply to your situation
I have been discriminated against due to a disability.
I have been discriminated against due to race.
I have been discriminated against due to religion.
I have been discriminated against due to sex.
I have been discriminated against due to age.
I have been discriminated against due to national origin.
I have been sexually harassed.
Since complaining, I am being retaliated against.
I have a severance package that needs to be reviewed.
Other
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Last date for severance package to be signed (mm/dd/yyyy)
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Date you were given the Severance Agreement (mm/dd/yyyy)
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What is your current employment status?
Still Employed
Laid Off
Fired
Quit
On Leave
Demoted
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Have you been terminated?
Yes
No
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If so, termination date (mm/dd/yyyy) ?
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If you were fired or laid off, what was the reason your employer gave you?
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Did you receive a Separation Notice or letter of termination from the Company?
Yes
No
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Are you currently on medical leave?
Yes
No
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If so, when did the leave begin (mm/dd/yyyy)?
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Are you currently receiving any disability pay?
Yes
No
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If so, what type and how much?
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If you believe you have been discriminated against, what makes you think this?
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Did you complain of discrimination?
Yes
No
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To whom ?
Supervisor
Upper Management
Human Resources
Other
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Has an EEOC Charge Been Filed?
Yes
No
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If so, on what date (mm/dd/yyyy)?
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What is the name of your EEOC investigator?
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Has a Notice of Right to Sue been issued?
Yes
No
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If so, on what date (mm/dd/yyyy)?
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If so, have you gotten a copy of your complete file from the EEOC?
Yes
No
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Please provide a brief description of what specifically has led you to contact us about your situation.
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Did the Company ever offer you Severance Pay?
Yes
No
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If yes, how much?
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Did you receive the Severance Pay?
Yes
No
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Did you ever sign a Release or other Agreement?
Yes
No
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If yes, please provide details.
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Has the Company offered you any settlement?
Yes
No
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If yes, how much?
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Do you have an Employment Contract?
Yes
No
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Have you ever signed an Arbitration Agreement with this Employer?
Yes
No
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Have you ever signed a Non-Compete or Non-Solicitation Agreement with this Employer?
Yes
No
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Are you currently taking medication for depression or anxiety?
Yes
No
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When did you start taking this medication (mm/dd/yyyy)?
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Are you currently represented by another Attorney on this matter?
Yes
No
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If so, who is the attorney? (full name and firm)
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Why is s/he not representing you moving forward?
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Have you filed for Bankruptcy within the past 5 years?
Yes
No
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If yes, what date did you file (mm/dd/yyyy)?
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Have you been discharged from bankruptcy?
Yes
No
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Is there any other information that you want us to know ?