Employment Law Intake Form
Thank you for your interest in Pines Bach LLP assisting you with your legal needs. This form is used to collect information about potential new clients for internal purposes only. The information you provide will be kept confidential and treated with the utmost discretion. Please note: fees vary among attorneys and the type of representation offered.
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pronouns:
*
Please Select
She/Her
He/Him
Them/They
Other
Alternative Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (please use a personal, non-work email address)
*
How did you hear about Pines Bach?
Client of Pines Bach
I am a previous client of Pines Bach
Google Search
Firm Website
Internet
Attorney/Judge
Bar Association
Other
Your Name
Name of Attorney/Judge
Back
Next
Were you referred to or requesting a specific Pines Bach attorney?
*
Yes
No
Name of referred to or requested attorney:
*
Employer Name
*
Is this the employer with whom you are seeking legal assistance with?
Please Select
Yes
No
Name of employer with which you have a dispute.
Name of Supervisor at the employer which you have a dispute
*
First Name
Last Name
What position do/did you hold?
*
Date of Hire
Do you work remotely?
*
Yes
No
Were you Terminated?
*
Yes
No
Date of Termination (if applicable)
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of employment matter
*
Severance/Separation Agreement Review
Non-Compete
Employment Agreement
Employment Investigation
Appeal or Grieve Employment Discipline
Discrimination, Harassment, FMLA violation, Whistleblower, or Wage Claim
Litigation Currently in Court (e.g., Dane County Circuit Court or the Western District of Wisconsin)
Disability Accommodation
Medical Leave (FMLA, short- or long-term disability, or other)
Professional Licensing
Other
Do you have an offer to go to work for a direct competitor doing the same/different kind of work as your current or former employer?
Please Select
Yes
No
Please provide a summary of the facts of your matter.
Do you have an employment agreement or contract?
*
Yes
No
Names of all parties involved (first and last names)
Are you a union member?
*
Yes
No
Name of Union
Have you contacted your union representative?
Yes
No
N/A
What, if anything, is the union proposing they can do to help?
Do you have any upcoming deadlines? (i.e., court dates, meetings, deadline for response?
*
Yes
No
If yes, nature of deadline and date:
If yes, please provide dates and type of discipline?
Have you filed a complaint with any of the following agencies (select all that apply)?
*
Please Select
Yes
No
*
Wisconsin Equal Rights Division (ERD)
U.S. Equal Employment Rights Commission (EEOC)
No complaint filed
Other
Name Other Agency:
If yes, what is the status of the complaint?
Filed, in investigation
Probable cause fopund
No probable cause found
Right to Sue letter issued
Appeal filed
Other
Submit
Should be Empty: