Request For Consultation
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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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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?
Yes
No
Required 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?!
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Do you have any concerns about how you are being paid?
Yes
No
Required Do you have any concerns about how you are being paid?!
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If so, please explain
Required If so, please explain !
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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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Have you been terminated?
Yes
No
Required Have you been terminated?!
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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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Please provide a brief description of what specifically has led you to contact us about your situation.
Required Please provide a brief description of 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.
Since complaining of discrimination, I am being retaliated against.
I have a severance package that needs to be reviewed.
Other
Please select at least one item.
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If you have been offered a severance package, what is the last date for severance package to be signed (mm/dd/yyyy)?
Required If you have been offered a severance package, what is the 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)
Required Date you were given the Severance Agreement (mm/dd/yyyy)!
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Are you currently on medical leave or have you taken a medical leave during the last year of your employment?
Yes
No
Required Are you currently on medical leave or have you taken a medical leave during the last year of your employment?!
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If so, when did the leave begin (mm/dd/yyyy)?
Required If so, when did the leave begin (mm/dd/yyyy)? !
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When did or will the medical leave end (mm/dd/yyyy)?
Required When did or will the medical leave end (mm/dd/yyyy)?!
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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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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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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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What is the name of your EEOC investigator?
Required What is the name of your EEOC investigator?!
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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 so, have you gotten a copy of your complete file from the EEOC?
Yes
No
Required If so, have you gotten a copy of your complete file from the EEOC?!
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If you have been terminated did the Company ever offer you Severance?
Yes
No
Required If you have been terminated did the Company ever offer you Severance?!
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If yes, how much?
Required If yes, how much?!
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Did you receive the Severance Pay?
Yes
No
Required Did you receive the Severance Pay?!
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Did you ever sign a Release or other Agreement?
Yes
No
Required Did you ever sign a Release or other Agreement?!
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If yes, please provide details.
Required If yes, please provide details. !
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Has the Company offered you any settlement?
Yes
No
Required Has the Company offered you any settlement?!
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If yes, how much?
Required If yes, how much?!
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Are you currently taking medication for depression or anxiety?
Yes
No
Required Are you currently taking medication for depression or anxiety?!
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When did you start taking this medication (mm/dd/yyyy)?
Required When did you start taking this medication (mm/dd/yyyy)?!
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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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Have you filed for Bankruptcy within the past 5 years?
Yes
No
Required Have you filed for Bankruptcy within the past 5 years?!
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If yes, what date did you file (mm/dd/yyyy)?
Required If yes, what date did you file (mm/dd/yyyy)?!
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Have you been discharged from bankruptcy?
Yes
No
Required Have you been discharged from bankruptcy?!
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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 ?!