Intake Form

Towards Justice Intake Form
Contact Information
EnglishSpanish
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?
She, Her, HersHe, Him, HisThey, Them, TheirPrefer not to answerOther
Cell phone number*
By providing your phone number, you authorize Towards Justice to contact you by phone or text message.Format: (000) 000-0000.
Additional phone number
Format: (000) 000-0000.
What is your email address?*

Confirmation EmailPlease type in your email address twice to confirm it is correct. If you don't have an email address, just write N/A.
What is your ZIP code?*
Employer Information
Who did you work for / what is the name of the Company you are seeking help with?*
Website of the Company you are seeking help with
Approximately how many workers work for the company or person you worked for?*
Legal Concern
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.
Recover moneyChange my employer’s practicesLearn more about my rightsOther
If you believe you are owed money, how much are you owed?
Please enter the amount without the dollar symbol.
Unpaid Wages (examples: employer provides bounced checks, refuses to pay, ignores communication, deducts hours from paycheck, or includes incorrect hours on pay stubs)Wage and Hours Violation (example: employer refuses to pay minimum wage and/or overtime pay)Misclassification (example: employer incorrectly categorizes a worker as an independent contractor when they legally should be classified as an employee)Unpaid Paid Time Off (including vacation and/or sick time)Hostile Work Environment/Harassment (example: failure to prevent and address harassment in the workplace, including sexual, racial, physical, or other forms of harassment)Retaliation and/or Wrongful Termination (example: being retaliated against after voicing concerns for oneself or others, being fired for taking these actions)Missing 30-minute meal time and/or 10-minute break timesPositive Determination Letter/waiting for owed collectionNon-Compete ContractsStay-or-Pay Contracts (example: employee must pay money back to the employer for training if they leave the company before the contract date)Threats to Call Authorities (including local police, state police, and ICE)Failure to Accommodate DisabilitiesFMLA/FAMLI Concerns and/or IssuesOther
YesNo
Race (includes ethnicity, ancestry, and national origin)Color (may include skin tone or complexion)Religion (includes religious beliefs, practices, and attire)Sex (includes gender identity, gender expression, and sexual orientation)National origin (includes the country of origin or ancestry)Age (typically protected for individuals 40 years of age and older)Disability (includes physical and mental disabilities)Genetic information (includes family medical history)Pregnancy and maternity (pregnant women and those on maternity leave)Citizenship or immigration status (discrimination based on your citizenship or immigration status)Primary language (primary language spoken or chosen to communicate in)Other
YesNo
Please explain the threats from your employer.
Employment Details
YesNo
Approximately what date did you start working?

MonthDayYear
It does not need to be exact.
Approximately what date did you stop working?

MonthDayYear
It does not need to be exact.
Difference between start date and end date
Please make sure that the date you stopped working is after the date you started working.
What are or were your job duties?
What state did you perform this work in?*
What city/town did you perform this work in?*
YesNo
YesNo
YesNo
YesNo
YesNo
Please explain the non-compete agreement.
Communications
YesNo
Who referred you?
YesNo
YesNo
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.
Should be Empty:

Towards Justice Intake Form

Contact Information

Employer Information

Legal Concern

Employment Details

Communications