Intake Form EN/SP Version

Please complete the intake form here

Por favor complete el formulario legal aquí
Select your language / Selecciona tu idioma*

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para ver la forma en Español

First name*
Name of person seeking legal help
Last name*
If you are completing this form on behalf of someone else, what is your name?
What pronouns do you use?*
Other pronouns
Cell phone number*
By providing your phone number you authorize Towards Justice to contact you by phone or text message
Additional phone number
What is your email address?*
If you don't have an email address just write N/A
What is your ZIP code?*
What is your end goal in reaching out for legal help?

Recover moneyChange my employer’s practicesLearn more about my rightsOther
Explain in detail the legal concern you are contacting us about?*
The more information you can provide our team, the better we are able to analyze your potential claim. If you were terminated/fired, please let us know if you believe you were terminated/fired because of your race, gender, sexuality, age, disability or for another reason. Also, if you believe you are owed money, please share how much money you are owed? Thank you.
Who did you work for? Or what is the name of the Company you are seeking help with?*
Website of the Company you are seeking help with?
Have you ever been threatened by the person or company you worked for because you raised these concerns to them or for any other reason?
If Yes, please explain
Around when did you start working?
Approximately, what date did you start working? (It does not need to be exact)
Approximate end working date
Approximately, what date did you stop working? (It does not need to be exact)
What are or were your job duties?
What state did you perform this work in?*
What city/town did you perform this work in?*
Did you receive 30-minute meal breaks?*
Did you receive 10-min breaks for every 4 hours of work?*
Did you ever work more than 40 hours in a week or 12 hours in a day?*
If you worked 40+ hours in a week or 12 hours in a day, were you paid overtime for this work?
Is there a non-compete agreement in your contract or anything else that prevents you from going to work for someone else?*
If Yes, please explain
Approximately how many workers work for the company or person you worked for?*
Were you referred to Towards Justice?*
Who referred you?
Would you like to be contacted in the future about ways to support us in advocating for better laws to protect workers and others like you?*
If needed, do we have your authorization to share your information with other Attorneys in our network? The shared information will remain confidential within our network of Attorneys. *
We are not able to offer individual legal representation to every person who fills out this form. Selecting Yes allows us to connect you with other legal resources.
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