Request For Consultation
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I am seeking a consultation for the following purpose: (Please select one)
Need contract review
Need review of restrictive covenants (non-compete, confidentiality etc.)
Need review of Separation (or Severance) Agreement
Need general advice on my rights and/or if I have a case
Other
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If you selected Other, please explain
Required If you selected Other, please explain!
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Date (mm/dd/yyyy)
Required Date (mm/dd/yyyy) !
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First Name
Required First Name!
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Last Name
Required Last Name!
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Mobile Phone # (xxx-xxx-xxxx)
Required Mobile Phone # (xxx-xxx-xxxx)!
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Private Email Address
Required Private Email Address!
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Home Address
Required Home Address!
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City
Required City!
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Zip
Required Zip!
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Who Referred You to Us
Required Who Referred You to Us!
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Your Sex
Male
Female
Transgender
Required Your Sex !
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Your Race
Required Your Race!
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Your Age
Required Your Age!
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Name of Employer you are contacting us about
Required Name of Employer you are contacting us about!
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Number of Employees
Required Number of Employees!
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Hire Date (mm/dd/yyyy)
Required Hire Date (mm/dd/yyyy)!
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What is the current or last position you held with this employer?
Required What is the current or last position you held with this employer?!
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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?
Required 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?!
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Do you have an Employment Contract?
Yes
No
Required Do you have an Employment Contract?!
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Have you ever signed an Arbitration Agreement with this Employer?
Yes
No
Required Have you ever signed an Arbitration Agreement with this Employer?!
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Have you ever signed a Non-Compete or Non-Solicitation Agreement with this Employer?
Yes
No
Required Have you ever signed a Non-Compete or Non-Solicitation Agreement with this Employer?!
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What is your current employment status?
Still Employed
Laid Off
Terminated
Quit
On Leave
Demoted
Please select at least one item.
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If you were terminated or laid off, what was your termination date (mm/dd/yyyy)?
Required If you were terminated or laid off, what was your termination date (mm/dd/yyyy)?!
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If you were terminated or laid off, what was the reason your employer gave you?
Required If you were terminated or laid off, what was the reason your employer gave you?!
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Briefly describe what specifically has led you to contact us about your situation?
Required Briefly describe what specifically has led you to contact us about your situation?!
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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.
I have a severance package that needs to be reviewed.
Other
Please select at least one item.
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If you believe you have been discriminated against, what makes you think this?
Required If you believe you have been discriminated against, what makes you think this?!
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Did you complain of discrimination?
Yes
No
Required Did you complain of discrimination?!
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To whom ?
Supervisor
Upper Management
Human Resources
Other
Please select at least one item.
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If you have been terminated did the Company ever offer you Severance Pay or a Settlement?
Yes
No
Required If you have been terminated did the Company ever offer you Severance Pay or a Settlement?!
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If yes, when did they offer it [date] and how much were you offered?
Required If yes, when did they offer it [date] and how much were you offered?!
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If you have been offered a severance package or settlement, what is the last date for the package or settlement agreement to be signed (mm/dd/yyyy)?
Required If you have been offered a severance package or settlement, what is the last date for the package or settlement agreement to be signed (mm/dd/yyyy)?!
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Have you received the Severance Pay?
Yes
No
Required Have you received the Severance Pay?!
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Have you signed a Release or other Agreement?
Yes
No
Required Have you signed a Release or other Agreement?!
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Have you taken a medical leave during the last year of your employment, and if so, how long were you out of work?
Required Have you taken a medical leave during the last year of your employment, and if so, how long were you out of work?!
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Are you currently receiving any disability pay?
Yes
No
Required Are you currently receiving any disability pay?!
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Has an EEOC Charge Been Filed?
Yes
No
Required Has an EEOC Charge Been Filed?!
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If so, on what date (mm/dd/yyyy)?
Required If so, on what date (mm/dd/yyyy)?!
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Has a Notice of Right to Sue been issued?
Yes
No
Required Has a Notice of Right to Sue been issued?!
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If so, on what date (mm/dd/yyyy)?
Required If so, on what date (mm/dd/yyyy)?!
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If yes, how much?
Required If yes, how much?!
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Are you currently or have you been represented by another Attorney on this matter?
Yes
No
Required Are you currently or have you been represented by another Attorney on this matter?!
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If so, who is the attorney? (full name and firm)
Required If so, who is the attorney? (full name and firm)!
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Why is s/he not representing you moving forward?
Required Why is s/he not representing you moving forward?!
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Is there any other information that you want us to know ?
Required Is there any other information that you want us to know ?!