Today's Date:

CLIENT INFORMATION

How were you referred to our law firm?

Friend or family member

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Another attorney

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Online search or lawyer directory website

Input the name of the website:

For example, 'Avvo', 'Facebook', or 'LawFirmName.com'

Billboard, bus stop, phone book, newspaper, or other physical advertisement

Where was the ad located?

Radio or TV advertisement

What radio or TV station?

Bar association

Which Bar Association?

Other

Please explain how you found us:

Preferred Contact Method:

Select an option Email Phone No Preference

Preferred Pronouns:

Select an option He/Him She/Her They/Them

Driver's License Number:

EMPLOYMENT DETAILS

Name and address of current or most recent employer:

Job title/position:

Start date of employment:

End date of employment:

(if applicable)

Were you employed full-time, part-time, temporary, or as a contractor?

Select an option full-time part-time temporary contractor

Are you a member of a Union?

Select an option Yes No

If so, what is the name of the Union?

CASE INFORMATION

What specific issue(s) are you seeking legal help with?

(e.g., wrongful termination, discrimination, unpaid wages, retaliation, harassment)

Please provide details, including dates, of the incident(s) that brought you to our office.

Please provide the names and titles of any Direct Supervisors or Managers that were involved in this issue.

Were you ever disciplined, demoted, or written up?

Yes

If yes, please provide more details.

No

Were you terminated or asked to resign?

Yes

If yes, when were you asked to resign and what reason was given?

No

Do you believe you were treated unfairly due to race, gender, age, disability, religion, sexual orientation, or another protected characteristic?

Yes

If yes, please provide more details.

No

Did you report any concerns to your employer or HR?

(e.g., harassment, safety violations, discrimination)

Yes

If yes, what did you report, when was it reported and how did the employer respond?

No

Have you filed a complaint with any government agency?

(e.g., EEOC, Department of Labor)

Yes

If yes, please provide more details including the result of the complaint.

No

Are there any witnesses who can support your claims?

Yes

If yes, please list their name as well as what they can attest to.

No

Do you have any written agreements, contracts, offer letters, termination notices or handbooks?

Yes

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E-ACKNOWLEDGEMENT

ACKNOWLEDGEMENT AND ACCEPTANCE

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