INITIAL CONSULTATION REQUEST

Contact Information Name: Address: Phone Number: Email Address: Best Time to Call You:

EEO Information Gender: M   F Age: Race/Color: National Origin: Religion: Pregnant? Yes   No Disabled? Yes   No If yes, what is the disability? Veteran? Yes    No If yes, what branch and dates?

Employer Information

Your concerns relate to your Current Employer  Former Employer?
Full name of your current/former employer:
Job Title:
Dates of employment
Start:   End:
How many employees work for your employer?
How are/were you paid? Hourly   Salary   Commission
Amount: $

Termination

Were you terminated? Yes   No

Reason given?

Areas of Concern

Select all that apply:

Description of Claim

Describe each act taken against you that you believe violates your legal rights, including the dates.


Discrimination/Harassment

On what basis do you believe you were discriminated against or harassed (if applicable)?
Gender
Age
Race/Color
National Origin
Religion
Pregnancy
Disability
Veteran Status

Were there any derogatory comments, jokes, slurs, graffiti or other communications directed toward you that referenced your membership in one of the above-listed EEO categories?
Yes   No

If yes, describe each communication, including the employee that made it and the dates.


Are there other employees who were treated better than you in the same situation (e.g., disciplined less severely for the same violation)?
Yes   No

If yes, explain:


Complaints Made

Did you complain to management about the actions taken against you? Yes   No

If yes, provide the details, including a description of what you said and the dates.


Actions Taken

Have you filed a lawsuit, EEOC charge, grievance, administrative appeal, arbitration demand, or taken any other action in an effort to resolve the matter in question?
Yes   No

If yes, describe the nature of the lawsuit or other action and the date filed.


Other Attorneys

Have you worked with any other attorneys in connection with this matter? Yes   No

If yes, provide the name, address and telephone number for each attorney and explain why you are no longer working with him/her.


Unemployment

Have you applied for unemployment insurance benefits? Yes   No

If yes, was your application for benefits Approved Not Approved?

Other Lawsuits/Legal Actions

Have you ever been a party to any other lawsuit or other legal action (including EEOC charges, administrative agency appeals, bankruptcies, divorces, collection actions, landlord/tenant matters, personal injury claims and small claims court matters)? Yes   No

If yes, describe the nature of the lawsuit or legal action, the date filed and the name of your attorney.


Ability to Pay

If required, are you able to pay an initial upfront retainer (typically, at least $2,500)? Yes   No

Referral Source

How did you learn of our firm?