Client Intake Form

First Name
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Last Name
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Phone
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Email
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Date of Birth e.g: 01/01/1970
Address
City
State
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Pronouns
How did you hear about us?
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Referred by? (If referred by someone, please let us know their name and/or Law Firm)
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Employment Information

This information helps determine what laws may apply

Name of Employer?
City and State of Employer
Approximate Date Employment Started?
Date Employment Ended?
Approximate Number of Employees at Your Location?
Your position/title?
Pay rate? (Please tell us your last hourly rate or annual salary)

Case Information

This information helps us determine what type of case this may be

Why do you believe you were treated differently? (Select all that apply)
- Sex or Gender
- Age
- Race
- Color
- National Origin
- Disability or Injury
- FMLA Request/Leave
- Religion
- Pregnancy
- Sexual Orientation
- Gender Identity
- Reporting or Complaints
- Other
If you chose "other", why else do you believe you were treated differently?
How were you treated differently? (Select all that apply)
- Terminated
- Harassed
- Forced to Quit/Retire
- Demoted
- Denied Accomodation
- Denied Benefits
- Disciplined
- Failed to Hire
- Failed to Recall
- Failed to Train
- Laid Off
- Suspended
- Transferred
- Unequal Pay
- Retaliated Against
- Other
For what reasons, if any, did your employer say you were terminated? Please provide a brief explanation of how your selections above played a role in your termination. Include names and job titles of persons involved and dates of events where possible.
Please provide a description of the severity and/or frequency of the harassment. Tell us when the harassment began, how long it lasted, and how, if at all, your employer responded to your complaints. Include names and job titles of persons involved and dates of events where possible.
Please provide a brief description of why you felt that your employer forced you to quit or retire. Include names and job titles of persons involved and dates of events where possible.
For what reasons, if any, did your employer say you were demoted? Please provide a brief explanation of how your selections above played a role in your demotion. Include names and job titles of persons involved and dates of events where possible.
Please provide a brief explanation of the accommodation(s) you requested and the reasons your employer gave you for denying your request(s). Include names and job titles of persons involved and dates of events where possible.
For what reasons, if any, did your employer say you were denied benefits? Please provide a brief explanation of how your selections above played a role in your denial of benefits. Include names and job titles of persons involved and dates of events where possible.
For what reasons, if any, did your employer say you were disciplined? Please provide a brief explanation of how your selections above played a role in your discipline. Include names and job titles of persons involved and dates of events where possible.
If the employer you applied to told you why you were not selected, please tell us the reason they provided you. Please provide a brief explanation of how your selections above played a role in your failure to hire.
Failure to Recall – For what reasons, if any, did your employer say they would not recall you? Please provide a brief explanation of how your of how your selections above played a role for why you were not recalled. Include names and job titles of persons involved and dates of events where possible.
For what reasons, if any, did your employer tell you why you would not receive training? Please provide a brief explanation of how your selections above played a role in why you did not receive training. Include names and job titles of persons involved and dates of events where possible.
For what reasons, if any, did your employer say you were laid off? Please provide a brief explanation of how your selections above played a role in your lay off. Include names and job titles of persons involved and dates of events where possible.
For what reasons, if any, did your employer say you were suspended? Please provide a brief explanation of how your selections above played a role in your suspension. Include names and job titles of persons involved and dates of events where possible.
For what reasons, if any, did your employer say you were transferred? Please provide a brief explanation of how your selections above played a role in your transfer. Include names and job titles of persons involved and dates of events where possible.
Please tell us your job title and pay rate. Please also provide the job title and payrate of the employee(s) receiving better pay than you. Please provide a brief explanation of how your selections above played a role in your unequal pay. Include names and job titles of persons involved and dates of events where possible.
Please provide a brief explanation of the complaints you made/concerns you raised that resulted in retaliation. Please provide a description of the severity and/or frequency of the retaliation. Tell us when the retaliation began, how long it lasted, and how, if at all, your employer responded to your complaints/concerns. Include names and job titles of persons involved and dates of events where possible.
If you chose "other", how else do you believe you were treated differently?
Briefly describe why you’re seeking legal assistance. Tell us whether you would like advice, representation, someone to negotiate your severance, etc.
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Employment Information

Case Information