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Intake Form

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All Information Below is CONFIDENTIAL

  • EMPLOYEE INFORMATION
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  • EMPLOYER INFORMATION
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  • REASONS FOR WRONGFUL CONDUCT
  • DISCRIMINATION
  • If you feel you have been discriminated against based on one of the above, please give specific examples that show that the unfair treatment is caused by the discrimination (such as, discriminatory remarks, different or unfair treatment, under-representation, etc.)
  • Please state if any witnesses to the discrimination and briefly describe what they might testify to:
  • JOB PERFORMANCE
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