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Direct: (626) 427-7128 ▪ Fax: (213) 342-6329 ▪ Email: marcia@guzmanandtokar.com

G&T INTAKE QUESTIONNAIRE/NEW CLIENT

Answer all questions to the best of your ability. Enter no or n/a if the question does not apply to you.
Today's Date

MonthDayYear
Enter either the date you begin the form or end.
BACKGROUND INFORMATION AND WORK HISTORY
General Info
Full Name*

First NameMiddle NameLast Name
Your Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
Alternate Phone Number*
Please enter a valid phone number.
Gender*

FemaleMale
Bithhday*

MonthDayYear
Date
Last 4 of SSN or TIN*
Enter the last 4 digits of your social security or Tax ID number
Racial or Ethnic Group*
Marital Status*

Single, never marriedMarriedDomestic partnershipWidowedDivorcedSeparated
How did you hear about us?*
Have you retained another law firm or representation?*
Emergency Contact Info
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Employer and Work Information
Did work occur in California?*
Company Name on Pay Stub or Wage Statement*
Employer's Headquarters Address*
Address of HQ or admin office where management, payroll, and/or HR are located.
Your Work Location*
Address where you performed your duties.
Business Owner *
(owners name and email address)
Total Number of Employees at Client's Location*
(estimate)
Number of Locations; How many employees at each location?
Address and Time Period Client Worked at Other Locations
Usual Schedule (days and hours)*
Date Hired*
If unsure of day, just enter month and year.
Date Terminated*
Last Day Worked*
Did you receive your last check?*

YesNoDo not know
Please indicate up to 3 positions you have held with the employer that you believe committed violations throughout your work history. Please include the information below as to 1) start date (mm-yy) of the position 2) end date (mm-yy) of the position 3) the title of the position 4) the salary/hourly rate for the position 4) name and position of your supervisor 5) and a brief description of the duties and responsibilities you performed in each position.

You MUST enter at least one, but not more than three. Start with your most current position.
Position 1 *
Position 2
Position 3
Termination
Reason for termination.*
Even if not true.
Real reason for termination.*
Summary of termination, in your own words.*
Did you ever make a report to Human Resources?
Legal Representation
Do you have any ongoing litigation with another law firm?
If yes, what is the name of law firm?
Have you signed a retainer with another law firm?
If yes, what is the name of law firm?
Reasons for Contacting Law Firm:

FEHA CLAIMS: Were you treated unfairly for any of the following reasons? If yes, explain and include any witnesses, dates, and other details.
Treated Unfairly Due To: If any apply, fill in the details.
Additional FEHA Related Questions
Did you feel harassed, bullied, teased, treated unfairly by employer, supervisor, or co-workers?
If you answered yes to previous question:
• Who harassed you?
• Can you list witnesses?
• Dates of harassment?
• Did you make an official complaint?
• To whom did you make complaint?
• Were any documents signed?
Enter details here.
Were you asked inappropriate questions during interview?
Did you request leave or take leave for disability or health?
Did you suffer any adverse consequences because of disability or in an attempt to go back to work?
Did you observe any Illegal or wrongful activity in workplace? (e.g. wage and hour violations, tax fraud, health and safety violations, discrimination etc.)
Have you filed claims against your employer with a government agency. For example, Labor Board, DFEH, or EEOC?
WAGE AND HOUR CLAIMS

Meal and Rest Breaks
Estimate how often your meal break was interrupted so that you did not receive full 30 min break.*
Example, once a week.
When you took meal break, were you 1) completely relieved of duties; and 2) allowed to leave premises?*
Did you work shifts longer than 10 hours? If yes, did you always take two meal breaks for shifts over 10 hours?*
What reasons were you given for not providing a timely, uninterrupted or full 30 minute meal break? *
Example, no staff to relieve you, too busy, management didn’t schedule breaks etc.)
Were you unable to take two rest breaks during 8 hour shift? If yes, how often?*
Did you ever take a rest break more than 3.5 hours into your shift? Estimate how often break was late.*
Was your rest break interrupted before ten minutes had passed? If yes, how often?*
How often was your rest break late, interrupted, or missed entirely?*
Reasons you were given for not having a timely, uninterrupted, or full 10-min rest break?*
Did you receive an additional hour of pay because you missed a meal or rest break?*
Did you ever agree to “waive” or not take meal or rest breaks?*
Off the Clock Work
Did you work a closing shift?*
Did you have to wait to leave premises after you’d clocked out?*
When you left premises, were you required to have your personal bag checked before you could leave? If yes, how often?*
How long did you have to wait to leave after having clocked out?*
Did you perform work related tasks after you clocked out? If yes, how often and for how long?*
Overtime
Were you ever told or caused to believe you were “exempt” from overtime pay?*
Did employer classify you as an “independent contractor”?*
Did you ever work more than 8 hours/day or more than 40 hours/week? If yes, how often?*
Estimate total hours over 8/day or 40/week you worked on average*
Did you receive overtime rate for this work?*
Expense Reimbursement
Did you have to pay for any business-related expenses (e.g. tools, uniforms etc.)*
Did you ever travel in your own vehicle for work-related activities? Were you reimbursed for mileage?*
Were you aware of any policy or procedure for requesting reimbursement from the employer for those expenses?*
Reporting Time
Did supervisor ever send you home before your worked the full shift you were scheduled for?*
Were you ever scheduled to work a shift less than 4 hours in length?*
Did supervisor ever send you home before you had worked at least 2 hours?*
Were you ever scheduled to work a shift that was longer than 8 hours?*
Did your supervisor ever send you home before you worked at least 4 hours?*
WITNESSES

It is important that we be able contact other persons who can support your claims, if possible. Please identify any co-workers or others who can confirm or add support to your claims:
Enter the name, contact information, job position/relationship and topics on which this person can speak.
Witness #1
Witness #2
Witness #3
Disability

If disability is not applicable, enter n/a in each box.
Do you have private disability insurance, either through a policy you purchased yourself or provided by your employer?*
If you have private disability insurance, what is the name of the company?*
Have you made a claim for disability insurance benefits?*
Was the disability insurance claim denied, approved or are you still waiting for adecision by the insurance company?*
Do you have a copy of the disability insurance policy?*
New Employment
Have you obtained new employment since your last employer?

YesNo
If yes, when did you start working for this employer?
What is your title?
What is your hourly rate?
Employer Name
Employer Address
Please review all entries and then click Submit.

(2022-12-27)
Should be Empty:

BACKGROUND INFORMATION AND WORK HISTORY

General Info

Emergency Contact Info

Employer and Work Information

Termination

Legal Representation

Reasons for Contacting Law Firm:

Additional FEHA Related Questions

WAGE AND HOUR CLAIMS

Off the Clock Work

Overtime

Expense Reimbursement

Reporting Time

WITNESSES

Disability

New Employment

Please review all entries and then click Submit.