Intake Form

EMPLOYEE INFORMATION

Name

Date

Email

Phone

EMPLOYER INFORMATION

Name of Employer

Approximate # of employees

Your job title

Are you part of a union? If so, which one

Type of Business

What was your salary or hourly wage?

Date of Hire

Date of Termination

If you were terminated, did you receive severance pay (more than the wages and vacation pay you were owed)?

Did you sign a written release when your employment ended?

Did you sign an arbitration agreement?

Do you believe the employer still owes you money for unpaid wages?

What type of unpaid wages?

Regular Hours
Overtime Hours
Unpaid Vacation

What type of Wrongful Action are you claiming?:

Termination
Failure to Promote
Demotion
Failure to Hire
Harassment
Unsafe work conditions
Failure to Pay Wages
Failure to provide meal breaks or rest breaks
Other

REASONS FOR WRONGFUL CONDUCT

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DISCRIMINATION

Do you believe that the employer's wrongful action was the result of discrimination based on one of the following? (Please check if applicable)

Sex
National Origin
Race
Disability

Disability Description

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Pregnancy
Was the employer aware of the pregnancy?
Sexual Harassment
Age
Retaliation
Whistle Blowing (i.e., complaining about illegal conduct by your employer or refusing to do something illegal)
Sexual Orientation
Other (describe)

Other 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.)

Discriminations Examples

Please state if any witnesses to the discrimination and briefly describe what they might testify to:

JOB PERFORMANCE

Evaluations

Wrongful Action(s)

Written Notice(s)

Name

This field is for validation purposes and should be left unchanged.

Intake Form

All Information Below is CONFIDENTIAL

PRACTICE AREAS