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Initial Consult Form – Employment Cases
INITIAL CONSULT FORM – EMPLOYMENT CASES
PERSONAL INFORMATION
Name
(Required)
First
Middle
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
(Required)
Date of Birth
(Required)
Month
Day
Year
Are you married?
(Required)
Yes
No
What is your spouse's name?
(Required)
Do you have children?
(Required)
Yes
No
Provide for each child:
(Required)
Name
Date of birth
Add
Remove
EMPLOYER INFORMATION
Name of Company:
(Required)
Company Home or Corporate Address:
(Required)
Provide the following information for the HOME or CORPORATE OFFICE of the employer.
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Approximate number of employees company-wide:
(Required)
Fewer than 10
Between 10 – 49
Between 50 – 100
More than 100
Other
Did or do you work at the home office address?
(Required)
Yes
No
Address of the location where you worked:
(Required)
If you worked at a different location, please provide the address of the location where you worked:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
YOUR EMPLOYMENT INFORMATION
Date of Hire
(Required)
Month
Day
Year
Current Employment Status:
(Required)
Fired
Resigned
Still employed
Other
If "other", please explain:
Last/current position held with this employer:
(Required)
Salary/wages:
(Required)
Name of your direct supervisor:
(Required)
First
Last
Title of your direct supervisor:
(Required)
Email address for your direct supervisor:
Has your employment ended?
(Required)
Yes
No
Date employment ended:
(Required)
Month
Day
Year
Who do you believe participated in the decision to end your employment:
(Required)
Please include all individuals who you believe played a role in the decisions that led to your employment ending. This might include the individuals who communicated a termination to you, supervisors, HR personnel, etc.
Name
Email Address
What do you believe this person did
Add
Remove
Provide any additional information about how your employment ended:
Tell us about any claims you made for unemployment benefits:
(Required)
I did not apply and do not plan to apply
I applied but have not yet heard back
I applied and was approved
I applied and was denied
Have you found other work?
(Required)
Yes
No, but I’ve been looking
No, and I have not been looking
Other
Please list all employers you have had since your employment ended:
(Required)
Name of Employer
Position Title
Start Date
Salary/Wages
Add
Remove
Briefly describe why you have not been looking for other work:
(Required)
Do you believe that your employer treated you less favorably than other employees for any of the following reasons (check all that apply):
(Required)
Race
Age
Sex
Gender identity
Sexual orientation
Disability or health
Religion
National origin
Marital status
Family status
I do not believe I was treated differently for any of these reasons
What is your race?
(Required)
What is your sex?
(Required)
What is your gender identity?
(Required)
What is your sexual orientation?
(Required)
What is the disability or health condition?
(Required)
What is your religion?
(Required)
What is your national origin?
(Required)
What is your marital or family status?
(Required)
If you selected anything above, please explain.
(Required)
Do you believe that your employer treated you less favorably or retaliated against you because you did one or more of the following things:
(Required)
Reported a work injury / pursued workers’ compensation benefits
Reported or complained about a workplace safety issue or an OSHA violation
Reported or complained about a regulatory compliance issue that my employer needed to follow
Reported or complained about harassment or discrimination based on race, age, sex, gender identity, sexual orientation, disability, religion, national origin
Fulfilled mandatory reporting obligations such as for child abuse or dependent adult abuse
Participated in another activity similar to the above terms
N/A
Select All
If you selected anything above, please explain.
Upload a copy or picture of your most recent paystub
(Required)
Please provide us with a copy or picture of your most recent paystub. If you take a picture, please ensure it is well light, includes the whole paystub, and is not blurry.
Max. file size: 50 MB.
Upload any other relevant paperwork you may have.
This may include, for example, performance reviews, discipline documents, termination documents, accommodation or FMLA documents, your resume, copies of complaints you made either internally or to an outside agency. If you have a large number of documents, please let us know and we can work with you to make the document exchange easier.
Drop files here or
Select files
Max. file size: 50 MB, Max. files: 50.
