Employment Law Intake Form If you are a human and are seeing this field, please leave it blank. First Name Last Name Maiden Name Address 1 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Date of Birth (mm/dd/yyyy) Age Social Security Number(###-##-####) Cell Phone Home Phone Work Phone Preferred Phone Number CellWorkHome Current Employer Email Where do you prefer us to send letters? EmailMailing Address Spouse/Significant Other Spouse Maiden Name Spouse Cell Phone Spouse Work Phone Date of Birth (mm/dd/yyyy) Employer How often do you want us to provide updates about your case? Never - Only when there is substantive movement (i.e. setting depositions, answering discovery, etc.)Monthly - But only if there has been some activity on the file (i.e. a routine phone call or letter).Monthly - even if no activity has occurred.Every 60 Days regardless of activity.Every 90 days regardless of activity. Type of discrimination (Mark all you think apply and specify how each category applies to you in the text area provided below): Race/Color/National OriginGender/SexDisability/HandicapReligion/CreedPregnancy/Maternity LeaveFamilial StatusAge(40+)Retaliation/WhistleblowerEqual PayMilitary StatusGeneticsDon't KnowNone of the above Explanation of selections above: Employer's Name Employer's Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Employer's Phone NumberPhone Date Hired (mm/dd/yyyy) Name of person who hired you: Date Employent Ended (if applicable) (mm/dd/yyyy) Name of person who fired you (if applicable) Date you were first discriminated/retaliated against (mm/dd/yyyy) Date you were last discriminated/retaliated against (mm/dd/yyyy) All postions held with employer and dates of each: Rate of pay with employer: Number of Employees employed by this employer: 0-78-1415-2425-4950-7475+ Name Race Job Title Name Race Job title Name Race Job Title Name Race Job title In the space provided please give a brief explanation of the events that have led you to believe you have been discriminated/retaliated against or treated wrongly by this employer: Did you receive written perfomance evaluations? if so, what ratings did you receive? If no longer employed by this employer, did you resign or were you fired? if you were fired, what reason(s) was given by your employer? If you resigned, what reason(s) did you give for your resignation? Were you disciplined (verbally, written, suspension, demotion, etc.) by this employer? If so, please describe each incident that led to the discipline and the discipline you received, and include the date you received each discipline and the date each event occurred that led to discipline. Do you know whether other employees have been accused or committed the same acts you were accused of and were treated differently by your employer (for example, others were not fired/disciplined for things you were)? If so, give complete details regarding each employee including name, race, gender, date, what the employee did, and who supervised the employee. In your own opinion, why were you treated differently by this employer? Did you complete a job application or submit a resume for this employer? Yes No If yes, was ALL of the information contained on the application/resume truthful and accurate? Yes No If not, please provide information as to what was inaccurate and how it was inaccurate. Have you ever been fired by any other employer? If yes, please state the employer, the reason given for the termination, and the date of the termination. Have you taken any of the following in the last 12 months? FMLAMaternity LeaveSick Leave If you took any leave in the last 12 months, was it: PaidUnpaidBoth What damages do you believe you have suffered as a result of this employer's actions? Please specifically indicate the wages you have lost, any out of pocket expenses (i.e. medical bills, COBRA payments, etc.), and emotional damages. Have you been treated by any mental health or medical professionals for any of your emotional damages or any other injuries that resulted from anything that your employer did to you? If so, please state each provider's name, address, dates of treatment, what you were treated for, and any medications prescribed by each provider. If no longer employed by this employer, please indicate all earnings (including unemployment compensation and wages from working) received since you left this employer. Were you given an employee handbook? Yes No Option 3 Have you ever seen a copy of an anti-harassment or anti-discrimination policy in your workplace? Yes No If Yes, Please describe: Background Questions Have you consulted any other attorneys regarding this matter? YesNo Have you previously claimed that any oter employer or any other entity has discriminated against you? YesNo Have you ever filed with Administrative Agencies? (EEOC, TN Human Rights Commission, TN Dept. of Labor, US Dept. of Labor, OSHA) YesNo Have you ever been injured on the job? YesNo Have you taken any medications from the time of the alleged incident to the present time, that you have not previously noted? YesNo Have you ever been diagnosed with a mental illness or disability? YesNo Have you ever been rendered physically disabled? YesNo Have you ever applied for any disability benefits? YesNo Have you ever applied for workers compensation benefits? YesNo Have you ever applied for unemployment benefits? YesNo Have you been paid for all time worked? YesNo Were you paid time-and-half for all over time (over 40 hrs/wk)? YesNo To your knowledge, have you received any bad or negative employment references from the employer that you believe discriminated against you? YesNo Are you a union member? YesNo If so, what union? Have you engaged in any union activities? YesNo Have you given any verbal, written, or recorded statement to any person regarding your claim? YesNo Have you ever been arrested? YesNo Have you ever sued or been sued? YesNo if you answered "yes" to any of the above please provide a brief explanation for each: Social Media If you use any of the following please provide user/screen name: Facebook Instagram LinkedIn Twitter Google+ Blog Any other online presence that can be seen by others on the internet: User/screen name of social media of spouse/significant other: User/screen name of any other friends/family members that may have posted about your case: Have you emailed anyone relating to the facts of the case? Yes No If terminated, have you contacted/attempted to contact anyone from the former employer since the termination? YesNo Have you texted anyone relating to th facts of the case? YesNo Have you commented/posted on Facebook about the employer? YesNo Have you taken/received pictures that may relate to the case? YesNo Have you taken/received audio recordings that may relate to the case? YesNo If you answered “Yes” to any of the above please attach or briefly explain of how to obtain copies. Please Note: If you have posted any information about your case to social media, or if you sent messages, e-mails, or texts about your case or employer, you MUST NOT ALTER OR DELETE THEM. They must be protected or maintained in original form. If such measures are not taken, your case could be dismissed by the court for tampering with evidence. Please ensure that your social media privacy controls are at the highest possible setting to protect against unintended disclosure of information by unauthorized parties. What would your ideal outcome be for this matter? Knowing that ideal outcomes are often not realistic, what outcome would you find acceptable? If applicable to your situation would you rather pursue this case to conclusion if you thought you could get more money (or a better result) or would you rather resolve the case earlier? If you could create your ideal attorney, what are two or three qualities he/she would have? On a scale of 1-5 please rate the services and qualities you value most: Returns calls the same business dayKeeps cost to a bare minimumAggressive, not prone to negotiateSends you frequent letters/emailsNicely furnished officeAvailable by cell phoneSeeks compromise when possibleWill drive to meet youHas a real person answer the phone
