Case Analysis Intake Form
All information and communications submitted through this intake form are strictly confidential and protected by the attorney–client privilege. By providing these details, you agree that no waiver of privilege occurs, and that all disclosures made in connection with this potential representation are intended to remain privileged and confidential.
Contact Information
Name
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First Name
Last Name
Phone Number
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Email
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example@example.com
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment Information
Employer/Company Name
Employment Start Date
Position Title (Most Recent)
Salary (or Hourly Wage)
Are you still employed?
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Yes
No
When did your employment end?
Were you offered a severance or separation agreement?
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Yes
No
Were you terminated or laid off in a reduction-in-force or reorganization?
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Yes
No
I don't know
Please describe how you found out that your employment was ending (including who informed you, what he/she said, and other details)?
Did you receive performance reviews?
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Yes
No
Were your performance reviews generally positive, negative, or neutral?
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Positive
Negative
Neutral
Were you ever given a written warning, placed on a performance improvement plan, or subject to performance-based discipline?
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Yes
No
If your position was eliminated, or you were laid off in a reduction-in-force/reorganization, did your job duties go away, were they reassigned to someone else, or was someone hired to take them over? (Please describe)
Do you believe that any of the following reasons contributed to your termination or discharge?
Age
Race
Sex
Disability
Medical reasons/medical leave
Making reports/complaints/opposing unlawful conduct
Other
Did supervisor, manager, team leader, or human resource personnel say anything or do anything that suggests the reason(s) identified above? If so, summarize the details of any relevant comments (who, what, when, etc.):
Please share any other details or information that you would like our attorneys to review:
By submitting this information, you acknowledge and agree that no attorney–client relationship is formed through this intake process. Tyler W. Brennan Law, LLC is not your attorney unless and until a formal retainer agreement is signed by both you and the firm.
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