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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Alternative Phone # (xxx-xxx-xxxx)
Required Alternative 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
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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Current or Last Position
Required Current or Last Position!
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Are you paid by the hour or do you get paid a salary?
Required 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?
Required 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?
Required 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
Required Do you receive 1.5 times your regular rate of pay if you work 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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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
Please select at least one item.
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Last date for severance package to be signed (mm/dd/yyyy)
Required 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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What is your current employment status?
Still Employed
Laid Off
Fired
Quit
On Leave
Demoted
Required What is your current employment status?!
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Have you been terminated?
Yes
No
Required Have you been terminated?!
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If so, termination date (mm/dd/yyyy) ?
Required 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?
Required 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
Required Did you receive a Separation Notice or letter of termination from the Company?!
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Are you currently on medical leave?
Yes
No
Required Are you currently on medical leave?!
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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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Are you currently receiving any disability pay?
Yes
No
Required Are you currently receiving any disability pay?!
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If so, what type and how much?
Required If so, what type and how much?!
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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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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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Did the Company ever offer you Severance Pay?
Yes
No
Required Did the Company ever offer you Severance Pay?!
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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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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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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 represented by another Attorney on this matter?
Yes
No
Required Are you currently 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 ?!