Colorado Springs Employment Law
Potential New Client Questionnaire
Introduction / Notices
This form is required for potential employee clients who are seeking an initial consultation with our office regarding possible legal claim(s) related to their employment.
PLEASE READ THIS: You are providing this information for evaluation by this firm in connection with a request for an initial consultation meeting. This firm does NOT agree to represent you because you complete this form. Submission of this form (and any other information or documents/attachments) does not constitute legal advice or form an attorney-client relationship.
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I understand.
PLEASE READ THIS: This firm will review and consider the information you provide via this form. We appreciate your interest and effort in providing information for our consideration. However, please understand that we cannot and do not provide a response to every potential client who contacts us and completes this form.
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I understand.
PLEASE READ THIS: If workload and current client obligations permit, we will notify you that we are interested in more information, and/or we would like to schedule you for a consultation.
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I understand.
PLEASE READ THIS: If you do not receive any additional response (apart from the automatic email receipt that confirms your successful submission) within 5 days, we are either (a) unable to provide a timely opportunity for a consultation, or (b) we do not assess that your matter(s) merit a consultation with this firm. In either event, we respectfully decline to offer you any legal advice and/or consider representation, and we therefore encourage you to contact a different law firm/lawyer.
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I understand.
PLEASE READ THIS: This firm does charge fees for initial consultations, which are payable in advance. In some instances, at our discretion, and depending on our review of the information you provide, we may waive those fees. Otherwise, if you are unable or unwilling to consider paying for our time to consider the details of your matter and provide preliminary advice, we encourage you to contact a different law firm/lawyer.
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I understand.
Any personal information that you submit will be kept confidential. We will not use that information for any other purpose or provide it to anyone else without your express consent.
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I understand.
To protect this submission from future disclosure in any legal proceeding related to this matter, you must not share or discuss it with anyone else.
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I understand.
Your Contact Information
We require this for our records and to be able to communicate with you.
Name
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First Name
Last Name
How do you want to be addressed (i.e. what pronouns do you use)?
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Mr./he/him
Ms./she/her
They/them
Email (please use only a private/personal address, NOT your work address)
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example@example.com
Phone Number (Note: we do NOT communicate via text message)
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Please enter a valid phone number.
Format: (000) 000-0000.
If necessary, may we leave you a voice message at this number?
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Yes
No
Please note that we will contact you via voicemail (as permitted) ONLY to facilitate direct communication via email or phone.
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I understand
Your residential (mailing) address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who referred you to this firm / how did you find us?
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Your Employer Information
Name of employer
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Is this employer a government agency or other public entity?
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Yes
No
I'm not sure
If this is a private employer, please state or estimate the total # of employees:
If this is a private employer, please state whether it has employees in more than one location(s), and where.
Your Employment Details
When did you begin working for this employer?
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Are you currently still working for that employer?
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Yes
No
If you answered NO above, when did that employment end?
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Month
-
Day
Year
Date
How did that employment end?
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I quit
I was fired
What was (or still is) your job title and job duties?
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If you were fired, what (if anything) did the employer tell you was the reason(s) for the termination?
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Your Employment Compensation and Benefits
What is the name of your employer as it appears on your pay stubs/W2s?
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How were you paid?
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Hourly
Salary
Commissions only
Other
If you answered "Other" about how you were paid, please explain.
What was your regular rate of pay (i.e., $20 per hour, $50K per year)?
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Were you full-time or part-time?
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Full-time (> 30 hours per week)
Part-time
What was your normal weekly work schedule?
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How many hours per 7-day workweek did you work, on average?
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Were you classified as exempt from overtime?
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Yes
No
Not sure
If you were not exempt from overtime, were you paid for any overtime that you worked? (>40 hours per 7-day workweek and/or >12 hours per single workday)
Yes
No
Were you paid for all of the time that you worked?
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Yes
No
Not sure
Did the employer provide you with any vacation leave or Paid Time Off (PTO)?
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Yes
No
If you answered "Yes" above, how much vacation leave/PTO did the employer give you (i.e. at what rate did you earn/accrue that time)?
If you had any accrued but unused vacation leave/PTO when the employment ended, did the employer pay you for that time?
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Yes
No
Proposed Separation Agreement?
Did the employer present you with any offer or proposed agreement related to your employment separation?
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Yes
No
If you answered "Yes" above, when did the employer provide you with that offer or proposed agreement?
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Month
-
Day
Year
Date
Did you accept the offer or sign that agreement?
Yes
No
Potential legal concerns/claims
Note: there are other potential legal concerns/claims not listed here, but these are the most common
Please select any/all potential legal concerns/claims that you wish to discuss.
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Discrimination because of race, color, national origin or ancestry (including racial harassment / racially hostile work environment)
Discrimination because of sex, sexual orientation, or gender identity (including sexual harassment / sexually hostile work environment)
Unequal pay (discrimination) because of sex
Discrimination because of religion or creed
Discrimination because of age (40 or older)
Discrimination because of your disability (accommodation) or retaliation because you requested accommodation of your disability
Discrimination because of your disability (unrelated to accommodation)
Discrimination because of pregnancy, recovery from childbirth, or breastfeeding
Retaliation because you opposed discrimination against someone else, or participated in someone else's claim(s) of discrimination
Retaliation because you complained about unsafe workplace conditions
Retaliation because you made a disclosure about improper financial action
Retaliation because you discussed your wages/compensation or other conditions of employment with another employee
Family/medical leave (including paid sick leave)
Payment of your earned wages (including commissions and/or bonus compensation)
Noncompete / nonsolicitation agreement(s)
Unemployment claim/benefits
Other contractual obligations / promises
If you selected either of the "disability" options above, what is your disability and how does it affect your ability to perform your job?
If you selected any of the "discrimination" options above, and/or retaliation related to discrimination, have you formally filed an administrative charge with the Equal Employment Opportunity Commission (EEOC) or the Colorado Civil Rights Division (CCRD)? (*Please note that submitting an initial intake and scheduling an interview with either agency does NOT constitute filing a charge.)
Yes
No
If you answered "Yes" above, what is the date that you formally filed your charge?
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Month
-
Day
Year
Date
If you answered "Yes" above AND have received a Dismissal and Notice of Right to Sue letter from EEOC and/or CCRD, what is the date of that letter? (NOTE: IF YOU RECEIVED A NOTICE OF RIGHT TO SUE LETTER, YOU HAVE 90 DAYS FROM THE DATE OF THAT LETTER TO FILE A LAWSUIT TO PURSUE YOUR CLAIM(S).)
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Month
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Day
Year
Date
If you filed a claim for unemployment, and you received a decision regarding your eligibility for benefits:
I was awarded unemployment benefits
I was denied unemployment benefits
If either you or the employer appealed the initial decision regarding your unemployment benefits, has that appeal reached a decision?
Yes
No, I received a notice of hearing for that appeal
Have you filed an administrative complaint with any of these agencies?
Colorado Department of Labor & Employment, Division of Labor Standards and Statistics
Occupational Safety and Health Administration (OSHA)
National Labor Relations Board (NLRB)
Other (please explain below)
If you indicated above that you did file a complaint with one of those agencies, WHEN did you file that complaint?
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Month
-
Day
Year
Date
Please provide a short summary of the FACTS that you believe are relevant to the potential legal concerns/claims that you identified above. (*Please avoid using words like "toxic", "hostile", "targeting", and legal terms such as "harassment" or "hostile work environment". Just describe what happened.)
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Please provide a short chronology / timeline that lists the key events in your situation.
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Have you filed, or do you intend to file, for bankruptcy?
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Yes
No
Initial Consultations
For most initial consultations (if we agree and schedule), and for mutual convenience, we prefer a virtual meeting via Zoom video. For Zoom meetings, please note that we require that you participate via a WiFi connection on a laptop or desktop computer or tablet, and NOT a cell phone. Please indicate if you are able to meet that way, or if you prefer a different format:
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I can do Zoom video via WiFi on a laptop/desktop/tablet
I prefer a telephone call
I prefer an in-person office meeting
Submit
Submit
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