Employee Intake Form

Intake Questionnaire

Deadline?

Is there a known deadline that you are facing?

(Please Explain)

Information

Date *

First and Last Name *

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Email *

Date of Birth

Gender

MaleFemale

Phone (Home)

Phone (Work)

Phone (Cell)

I prefer to be contacted by phone

At homeAt workBy cell phone

Best time to call

How were you referred to / or learned of our office?

WHO IS YOUR COMPLAINT AGAINST

Name of company

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone

Type of business

Location(s) elsewhere

YesNo

Location where tort occurred (explain)

Company size

Less than 1515 to 5051 to 100101 to 200201 to 500500 or more

Name(s) of Individual(s)

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Do you believe that the company / individual violated an agreement with you?

YesNo

If yes, which agreements did the company/individual violate?

Are you union represented?

YesNo

Which union?

IF YOUR COMPLAINT IS AGAINST YOUR EMPLOYER

Please check any that apply to your relationship with employer

Owner or founderStockholderStockholder of more than 5% of outstanding sharesExempt (full time)Non-exempt (full time)Independent contractorPart-time employee

Explain how you fit into the organization (if applicable):

Your date of hire

Your date of demotion or termination (if applicable)

Department / division you worked in

Your position title

Date you were assigned to this position

Your wage / salary

Benefits

Your immediate supervisor's name

Your immediate supervisor position's title

Do you have an Employment Agreement, Stock Option, Covenant Not to Compete, Non- Solicitation Agreement, or any other agreement or contract with your Employer? If yes, please contact us for instructions as to how to submit a copy (unless they do not relat

YesNo

Have you signed any Severance Agreement or Separation Package with your employer? If yes, please contact us for instructions as to how to submit a copy.

YesNo

Have you been presented with any type of Severance/Separation Agreement or Package but have not yet signed? If yes, please contact us for instructions as to how to submit a copy, along with any questions or concerns relating to the Agreement.

YesNo

Have you filed any complaints against your employer?

YesNo

When? What did you specifically allege in each complaint? What was the agency's disposition of your complaint? (for complaints filed with administrative agencies)

Is your security clearance at risk? *

YesNo

If yes, please explain

Employee Intake Questionnaire

Intake Questionnaire

Deadline?

Information

WHO IS YOUR COMPLAINT AGAINST

IF YOUR COMPLAINT IS AGAINST YOUR EMPLOYER

Verification