Problems on the Job? - Prospective Client Intake Form

  • Prospective Client Intake Form

    Please complete this form to proceed with a consultation. On the consultation call, an Attorney will discuss the details of your case with you and talk about your options going forward.  

    One of three outcomes is possible following your consultation.

    1. You and the Attorney will agree to terms of representation and sign an engagement letter containing those terms. 

    2. The Attorney declines representation.

    3. You decide not to use the services of the Attorney.


    NOTE: The following questions will help us to understand the reason for your visit today. Your responses are protected by attorney/*client* privilege and will be held in strict confidence.

     

    • TELL US ABOUT YOU 
    • Format: (000) 000-0000.
    • Date of birth*
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    • TELL US ABOUT WHERE YOU WORK 
    • Format: (000) 000-0000.
    • WHY ARE YOU SEEKING COUNSEL? 
    • YOUR EMPLOYMENT 
    • Date of hire*
       - -
    • Date of termination
       - -
    • Do you have a copy of the employee handbook or personnel manual?*
    • Do you have copies of your performance evaluations?*
    • Have you been placed on a performance improvement plan?*
    • Do you have an employment contract?*
    • Are you a member of a union with the employer?*
    • WHAT STEPS HAVE YOU TAKEN PREVIOUSLY? 
    • Have you filed a charge with the Equal Employment Opportunity Commission (EEOC) or the local Human Rights Office?*
    • When did you file the charge?
       - -
    • Did you receive a right-to-sue letter?*
    • Date right-to-pursue letter received?
       - -
    • Have you filed a lawsuit about this claim*
    • TELL US ABOUT YOUR PROBLEM? 
    • When did your problem first start?*
       - -
    • When did your problem end?*
       - -
    • Did you complain to anyone at work about it?*
    • Are these people supervisors or human resources?*
    • Do you think the reasons given are not true?*
    • Did anyone witness the incident(s) described above?*
    • Do you have written documentation?*
    • Have other employees had problems similar to yours? *
    • If you were discharged, have you been given any documents to sign?*
    • Did your employer violate their own policies?*
    • DAMAGES/INJURIES  
    • Are you currently working?*
    • Do you have any medical conditions or disabilities?*
    • Have you undergone any psychiatric or psychological treatment*
    • Do you have a therapist, psychiatrist or psychologist?*
    • Do you take any medication for emotional issues related to the incidents?*
    • Have the incidents affected your physical health?*
    • Have you consulted with a doctor about the incidents?*
    • Do you take any medication for physical health issues related to the incidents?*
    • DISCLOSURE & SUBMISSION 

    • PLEASE READ CAREFULLY and SIGN BELOW:

      Following your initial interview, if you agree to hire the Attorney, and the Attorney agrees to represent you, you will both sign Terms of Engagement Letter. The Letter will set forth the terms and conditions of representation. If the Attorney is willing to represent you and you decide not to sign a Terms of Engagement Letter, you are strongly urged to follow up with the Attorney as soon as possible or to immediately consult with other legal counsel to protect your rights.

      NOTICE: Completing this form does not create an attorney-client relationship.  Our consultations also do not create an attorney-client relationship.  We are only your attorneys if both you and the attorney sign a terms of engagement letter.  If the attorney does not agree to represent you, this includes not representing you with regard to any matter.  

      Responding to legal problems is time-sensitive.  Until you are represented by an attorney it is your responsibility to understand the time limits on filing your case, called statutes of limitations. Therefore, we strongly urge you to immediately consult with another attorney to protect your rights. If we decide not to repesent you is, it is not an expression regarding the merits of your case.

       

    • By typing name below, you electronically sign your intake form and confirm that you have read the disclosure and agree to its terms. 

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