Worker Referral Form
For our Legal Partners
Referring Attorney
Please provide your contact information so we can be in touch with you.
Your Name
*
First Name
Last Name
Firm or Organization Name
*
Your email
*
Would you like to receive emails from HCJF about CLEs and other programs?
*
Yes
No
Your Firm's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Case Referral
Please provide some basic facts and contact information so that we can follow up with the worker.
Worker's Name
*
First Name
Last Name
Worker's preferred pronouns
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Have you received permission from the worker to share their contact information with us?
*
Yes
No
Worker's Primary Language(s)
Worker's Estimated Household Income
Number of Dependents
Which of these issues would the worker like help with? (Check all that apply)
*
Recovering unpaid wages
Applying for unemployment benefits in Missouri
Appealing a denial of unemployment benefits in Missouri
Reporting a safety complaint to OSHA
Reporting a whistleblower complaint to OSHA
Other
Is the worker classified as an employee or an independent contractor?
Employee
Independent contractor
Independent contractor, but potentially misclassified
Not sure
If you marked other, please describe in more detail:
If the worker's unemployment benefits were denied, has it been less than 30 days since the denial?
*
Yes
No
Not sure
If the worker was retaliated against for reporting a safety concern, has it been less than 30 days since the alleged retaliatory action?
*
Yes
No
Not sure
Please provide any additional information that will help us when we contact this worker.
Submit
Should be Empty: