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Intake Form

Client Intake Form
The purpose of an initial consultation is for the Attorney to advise you, the prospective client on what if anything, may be done for you, and what the associated fees will be. The purpose is not to render a definitive legal opinion as it may be impossible to fully assess a matter within the time frame allotted for a consultation or with the (information or documents) that may be provided at the initial consultation

One of three outcomes is possible following your consultation.

A. You and the Attorney will mutually agree to the terms of representation, then a separate document called an Engagement letter is signed and a copy will be provided to you.

B. The attorney declines representation.

C. You decide not to use the services of the Attorney.

NOTE: The following questions will help us to understand the reason for your visit today. Your responses are protected by attorney/client privilege and will be held in strict confidence.

Personal Information
Full Name *

First Name Last Name
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
example@example.com
Mobile Number *
Social Security *
Birth Date *

Day Month Year

Business Information
Employer Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Email *
example@example.com

Reason for Contact
Check all that apply: *

Breach of Contract Non-Compete Agreement Termination of Employment Failure to Promote Denial of Benefits (e.g., wages, pension, insurance) Failure to Hire Violation of Employer's policies Severance Agreement Sexual Harassment Racial Harassment Other
Discrimination *

Age Disability Illness/Injury Marital Status National Origin Pension ( or other benefit Status) Pregnancy Race Religion Retaliation Sex (gender) Sexual Orientation Workers Compensation Claim
Date of Problem *

Month Day Year
Date

Terms and Conditions of your Employment
Are you a member of a union with the employer? *

Yes No
If Yes, what is the union's name?
Are you a party to a contract? *

Yes No
Did you receive a letter at the time of your hire that set out the terms of your employment? *

Yes No
Did you receive an employee handbook or personnel manual when you were hired or at any time during your employment? *

Yes No
If No. does the company use a manual or set of policies?

Yes No Other
How do you know? *

0/250
Do you have copies of your performance evaluations? *

Yes No
What ratings have you received over the past 5 years? *

0/100
Please explain rating scale *

0/140

Previous Activity
Have you filed a charge with the Equal Employment Opportunity Commission (EEOC) or the local Division of Human Rights *

Yes No
If Yes, which organization did you contact?
When did you file the charge?

Month Day Year
Date
Did you receive a right-to-pursue letter? *

Yes No
Date right-to-pursue letter received?

Month Day Year
Date
Have you filed a lawsuit about this claim *

Yes No

Discrimination/Harassment
Is this a Discrimination or Harassment Issue? *

Yes No
When were you subjected to harassment and/or discrimination?

Month Day Year
Start Date
When were you no longer subjected to harassment and/or discrimination?

Month Day Year
End Date
Who is/was harassing you and/or discriminating against you?
What happened to you to prompt this complaint?
What was your immediate reaction to the harassment/discrimination?
Who was the first person you spoke to about the harassment/discrimination?
Did you ever protest this treatment?

Yes No
What were the reasons given to you for your treatment?
Do you feel that the reasons given to you were false or insufficient?

Yes No
What do you think is the real reason for the treatment?
Did anyone witness the incident(s) described above?

Yes No
If Yes, state the name of the individual who witnessed each incident.
With whom have you discussed the incident(s)?
Describe how you informed your spouse and family of the harassment/discrimination.
How many of your coworkers do you believe knew about your situation?
How did the coworkers find out?
Have you previously been subjected to harassment or discrimination by the individual(s) identified in your responses above?

Yes No
If Yes, please describe each prior incident in detail.
Do you have written documentation relevant to your complaint?

Yes No
If Yes, describe the document(s).
Are you aware of other employees who have experienced harassment or discrimination by the person harassing or discriminating against you?

Yes No
If Yes, state the employee's name and the details of his or her experiences, if known to you.
When/if you were discharged, did you sign a resignation letter, waiver, or release document?

Yes No
If Yes, describe the circumstances under which you signed?
Do you believe the employer's actions violated its own procedure or policies?

Yes No
If Yes, explain?

Damage/Injuries
Are you currently working? *

Yes No
If No, what is the date that you last worked?

Month Day Year
Last Date Worked
Why did you stop working?
Are you disabled? *

Yes No Prefer Not To Say
If you are on disability, identify the medical provider who placed you on leave?
Are you taking any medications? *

Yes No
If you were prescribed any medication(s), list each medication and the date(s) prescribed?
Have you undergone psychiatric or psychological treatment? *

Yes No
If Yes, identify provider(s):
Were you required to take any medication for emotional problems related to the incident? *

Yes No
Has this incident affected your physical health? *

Yes No
If this employment action has affected your physical health, what was the nature of these problems?
Did you consult a medical doctor? *

Yes No
If Yes, identify provider(s)
Were you required to take any medication for the medical problems related to the incident? *

Yes No
Describe any medical expenses, as a result of the employment dispute, which are not covered by insurance.
What is your wage loss at the present time? *
What non-monetary losses or injuries have you and your family suffered as a result of the employer's actions? *
What other economic losses have you suffered in relation to the employment dispute (e.g., stock options, profit-sharing, lost and/or reduced wages, etc.) *

Disclosure & Submission
PLEASE READ CAREFULLY and SIGN BELOW:

Following your initial interview, if you agree to hire the attorney, and the Attorney agrees to represent you, you will both sign an Agreement for Representation. The Agreement for Representation will set forth the terms and conditions of representation. If the Attorney is willing to represent you and you decide not to sign an Agreement for Representation today, you are strongly urged to schedule the second appointment with the Attorney at the earliest possible or to immediately consult with other legal counsel to protect your rights.

NOTICE: This office does not represent you with regard to the matters set forth by you herein in this information sheet or discussed during your consultation unless and until, both you and the Attorney execute a written Agreement for Representation. If the Attorney does not agree to represent you, this includes not representing you with regard to the matter set forth by you on this information sheet, nor any other matters you may discuss with the Attorney during your consultation. If your legal problem(s) involve a potential lawsuit, it is important that you realize a lawsuit must be filed within a certain period of time called Statute of Limitations. Therefore, the Attorney strongly urges you to immediately consult with another Attorney to protect your rights. The Attorney's decision not to repesent you should not be taken you as an expression regarding the merits of your case.
*

Yes, I agree / Understand
Your signature acknowledges only that "you" submitted a copy of this completed information sheet and does not mean you hired an Attorney.
Sign Your Name Here *

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