Employment Law Intake Form

*Name:

*Address:

*City:

*State:
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*Zip:

*E-mail address:

*Home Phone:

Business Phone:

Cellular or Pager:

Facsimile:

Does this matter involve a business you own or run?
Yes  No 

If yes, provide the business name, address, and phone:

Describe your situation, including any relevant dates:

Does this matter concern a complaint, or threatened complaint, regarding employment practices?
Yes  No 

If yes, please provide the name and address of the person or persons involved:

Is the person involved a current
employee  former employee  job applicant  or prospective employee   of yours?

Is the person involved a union member?
Yes  No 

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

Has a complaint been made about your situation to any governmental agency?
Yes  No 

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

Are any other people involved, other than those listed above?
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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