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
City
Zip
Who Referred You to Us
Your Sex
Male
Female
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?
Yes
No
Do you have any concerns about how you are being paid?
Yes
No
If so, please explain
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
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?
Still Employed
Laid Off
Fired
Quit
On Leave
Demoted
Have you been terminated?
Yes
No
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?
Yes
No
Are you currently on medical leave?
Yes
No
If so, when did the leave begin (mm/dd/yyyy)?
Are you currently receiving any disability pay?
Yes
No
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?
Yes
No
To whom ?
Supervisor
Upper Management
Human Resources
Other
Has an EEOC Charge Been Filed?
Yes
No
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?
Yes
No
If so, on what date (mm/dd/yyyy)?
If so, have you gotten a copy of your complete file from the EEOC?
Yes
No
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?
Yes
No
If yes, how much?
Did you receive the Severance Pay?
Yes
No
Did you ever sign a Release or other Agreement?
Yes
No
If yes, please provide details.
Has the Company offered you any settlement?
Yes
No
If yes, how much?
Do you have an Employment Contract?
Yes
No
Have you ever signed an Arbitration Agreement with this Employer?
Yes
No
Have you ever signed a Non-Compete or Non-Solicitation Agreement with this Employer?
Yes
No
Are you currently taking medication for depression or anxiety?
Yes
No
When did you start taking this medication (mm/dd/yyyy)?
Are you currently represented by another Attorney on this matter?
Yes
No
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?
Yes
No
If yes, what date did you file (mm/dd/yyyy)?
Have you been discharged from bankruptcy?
Yes
No
Is there any other information that you want us to know ?