Employment Law - Employee Intake Form

*Name:

*Address:

*City:

*State:
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*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Please provide the name and address of the employer involved:

Are you a current
employee  former employee  job applicant  or prospective employee  of this employer?

Are you presently employed?
Yes  No 

If yes, please provide your job title and employer's name and address.

Can you be contacted at work?
Yes  No 

Describe your situation, including any relevant dates:

Are you a union member?
Yes  No 

If yes, provide the name, address, and local number:

Have you made a complaint about your situation to any governmental agency?
Yes  No 

If yes, provide the name of the agency, the date you made your complaint, and the final result, if any, of your complaint:

Are any other people involved?
Yes  No 

If yes, provide names, addresses (if known), and their relationship to you, if any:

Do you have any documents that could help explain your situation?
Yes  No 

If yes, list those documents and their dates:

Are there other documents that you do not have access to that could be of assistance?
Yes  No 

If yes, list those documents and their dates and locations (if known):

Describe how this situation has impacted you:

Describe what you would like to happen to resolve your issue (your preferred outcome):

Have other attorneys worked on this matter?
Yes  No 

If yes, provide names, addresses, and a brief description of their involvement:

Special concerns:

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