Intake Questionnaire

IDENTIFYING INFORMATION

NAME

First Name

Last Name

FULL MAILING ADDRESS

STREET

STATE

ZIP CODE

COUNTRY

TELEPHONE NO

HOME

(###)

###

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WORK

(###)

###

####

CELL

(###)

###

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PREFERRED METHOD OF BEING CONTACTED

EMERGENCY CONTACT

EMERGENCY TEL

DATE OF BIRTH

YYYY

PLACE OF BIRTH

LANGUAGE YOU ARE PROFICIENT IN

MARITAL STATUS

FILL IF MARRIED(as mentioned below)

NAME OF SPOUSE SEX RACE NATIONAL ORIGIN COLOR DISABLED : YES/NO IF SO, NATURE OF DISABILITY MILITARY HISTORY : YES / NO / HONORABLE DISCHARGE COMPANION CASE NAME: (FILL IN IF ANY )/ NONE

CRIMINAL HISTORY

If yes, describe including the names of any counsel used:

Describe any expunged offenses/convictions or juvenile offenses:

PRIOR LAW SUITS

If yes, describe including the names of any counsel used:

Have you ever alleged prior to this incident that you have been the subject of harassment or discrimination:

If yes, describe

PRIOR TERMINATIONS FROM EMPLOYERS

If yes, describe:

PRIOR JOB HISTORY(fill as described below)

Dates Title Salary Reason for leaving

EMPLOYMENT INFORMATION/ADVERSE PARTY

NAME OF EMPLOYER

MAILING ADDRESS OF EMPLOYER

COUNTY

ADDRESS OF YOUR ASSIGNED WORK LOCATION

PHONE NO. OF EMPLOYER

(###)

###

####

TYPE OF BUSINESS

ESTIMATE TOTAL # OF EMPLOYEES IN COMPANY

BENEFITS YOU ARE RECEIVING

DEPARTMENTS YOU WORKED IN

DESCRIBE YOUR DUTIES FOR EACH POSITION

WHAT WAS THE DATES OF SUPERVISION AND NAME, RACE, ETHNICITY, AGE, AND GENDER OF YOUR SUPERVISOR:

FILL IN AS BELOW (About your Supervisor) Dates of Supervision Name Race Ethnicity Age Gender

WERE YOU EMPLOYED

HOW DID YOU FIND THIS JOB

REQUIREMENTS FOR JOB (EDUCATION, SPECIAL TRAINING, ORIENTATION, ETC.):

FILL IN AS BELOW Education Special Training Orientation

SUPERVISORY DUTIES AND NUMBER OF EMPLOYEES SUPERVISED?

WHO INTERVIEWED YOU FOR THE POSITION

WHO OFFERED YOU THE POSITION

DID YOU WORK IN A PARTICULAR DEPARTMENT OR UNIT, IF SO, WHICH ONE

DID YOU BELONG TO A UNION

IF SO, WHICH ONE

WORK RECORDS

DID YOU FILL OUT AN APPLICATION FOR EMPLOYMENT FOR THIS POSITION

DO YOU HAVE A COPY OF IT

WHEN YOU WERE HIRED, OR AT ANY TIME DURING YOUR EMPLOYMENT, WERE YOU GIVEN AN EMPLOYEE HANDBOOK, OR ANY DOCUMENTS THAT DESCRIBED THE COMPANY’S OR AGENCY’S RULES AND REGULATIONS:

IF SO, YOU HAVE THESE DOCUMENTS

DOES THE COMPANY HAVE A POLICY ON REPORTING HARASSMENT/DISCRIMINATION

IF YES, DO YOU HAVE IT/KNOW IT

DOES THE COMPANY REQUIRE TRAINING ON HARASSMENT/DISCRIMINATION

WERE PERIODIC EVALUATIONS GIVEN TO EMPLOYEES

IF SO, WERE YOU GIVEN ANY EVALUATIONS

DO YOU HAVE COPIES OF ANY OF YOUR EVALUATIONS

HOW WERE YOUR EVALUATIONS

DO YOU HAVE A COPY OF YOUR PERSONNEL FILE ?

HOW WERE THE EMPLOYEES TIME AND ATTENDANCE DOCUMENTED:

ARE THERE ANY EMPLOYMENT DOCUMENTS THAT YOU HAVE THAT YOU SHOULD NOT HAVE

DID YOU MAINTAIN A DIARY OR LOG OF WHAT OCCURRED

ADVERSE EMPLOYMENT ACTION

HAVE YOU BEEN SUBJECT TO AN ADVERSE EMPLOYMENT ACTION (TERMINATED, DEMOTED, SUSPENDED WITHOUT PAY, REASSIGNED, HOURS OF EMPLOYMENT CHANGED, TRANSFERRED, PAY REDUCED, ETC.)

WHAT WAS THE ADVERSE EMPLOYMENT ACTION

WHEN

YYYY

BY WHOM

SEX, AGE, RACE OF PERSON

Please seperate by commas

WHAT WAS THE REASON GIVEN FOR EACH ADVERSE EMPLOYMENT ACTION, IF ANY

HAVE YOU EVER ENGAGED IN ANY ACTION WITH THE HARASSER THAT MAY BE CONSTRUED AS WELCOMING THE HARASSER’S ACTIONS (e.g. went to lunch with individual, sent gifts, socialized with individual, exchange of social e-mails/correspondence/pictures and/or jokes, other, etc.)?

PLEASE PROVIDE A CHRONOLOGY OF THE HARASSMENT/ DISCRIMINATION (Please provide, in chronological order, dates, names, and specifics of harassment/ discrimination; if you have a separate chronological statement/journal please attach a copy.) NOTE: IF YOU LEAVE THIS PORTION BLANK, THE FIRM MAY REQUIRE YOU TO RESCHEDULE YOUR CONSULTATION OR MAY REQUIRE ANOTHER CONSULTATION.

DO YOU KNOW OF ANY OTHER EMPLOYEE WHO WAS ALSO SUBJECTED TO SAME ADVERSE EMPLOYMENT ACTIONS, AT ANY TIME, FOR THE SAME REASON:

HAVE YOU BEEN DISCIPLINED OR REPRIMANDED WHILE AN EMPLOYEE: IF YES, PLEASE PROVIDE DETAILS WITH NAME OF PERSON(S) WHO DISCIPLINED YOU/REPRIMANDED YOU, THE NATURE OF THE REPRIMAND, AND THE DATES OF THE REPRIMAND:

OTHER ILLEGAL/IMMORAL/UNETHICAL ACTIONS OR FINANCIAL MISCONDUCT OR HEALTHCARE FRAUD OF YOUR EMPLOYER? If yes, please detail:

LOSSES OR DAMAGES

ARE YOU CURRENTLY WORKING?

IF YES, NAME OF EMPLOYER AND ADDRESS

IF YES, CURRENT SALARY

IF YES, TITLE OF POSITION

IF YES, LIST OF BENEFITS

IF YES, DATES OF EMPLOYMENT

WHAT OTHER INCOME HAVE YOU RECEIVED POST-EMPLOYMENT

WHAT EFFORTS HAVE YOU TAKEN TO FIND ALTERNATIVE EMPLOYMENT

HAVE YOU FILED FOR UNEMPLOYMENT

IF NOT, WHY NOT

HAS YOUR EMPLOYER CONTESTED YOUR APPLICATION UNEMPLOYMENT BENEFITS

IF SO, ON WHAT GROUNDS

HAS THERE BEEN A HEARING HELD FOR YOUR UNEMPLOYMENT BENEFITS

IF SO, WHEN

WHAT WAS THE OUTCOME OF THIS HEARING

ARE YOU TREATING WITH ANY DOCTORS

IF YES, CONTACT INFORMATION

COMPLAINTS

HAVE YOU EVER COMPLAINED EITHER ORALLY OR IN WRITING ABOUT ANYTHING TO YOUR UNION, OR TO ANY SUPERVISOR OR MANAGER

IF SO, DESCRIBE THE NATURE OF YOUR COMPLAINT(S

DO YOU HAVE ANY COPIES OF YOUR COMPLAINT(S):

DESCRIBE THE OUTCOME OF YOUR COMPLAINT(S). WHAT ACTIONS, IF ANY WERE TAKEN

HAVE YOU FILED ANY COMPLAINTS WITH ANY GOVERNMENT AGENCY AGAINST YOUR EMPLOYER

ACTIONS OCCURING AFTER ADVERSE ACTION

WERE YOU OFFERED OR DID YOU RECEIVE ANY SEVERANCE PAY

IF SO, HOW MUCH

WERE YOU OFFERED A DIFFERENT POSITION WITHIN THE COMPANY OR AGENCY

IF SO, DID YOU ACCEPT OR REJECT IT

IF YOU REJECTED THE DIFFERENT POSITION, EXPLAIN WHY

IF SO, DESCRIBE IT, AND DESCRIBE WHERE WAS IT LOCATED

DID YOUR EMPLOYER OFFER TO HAVE YOU SIGN A GENERAL RELEASE

HAS ANYONE BEEN HIRED TO REPLACE YOU

HOW DID YOU FIND OUT

WHAT IS THE GENDER, AGE, NATIONAL ORIGIN, OR RACE OF THE PERSON WHO WAS HIRED TO REPLACE YOU

ARE THE DUTIES OF YOUR REPLACEMENT SIMILAR TO THE ONES YOU PERFORMED

RELIEF YOU ARE SEEKING

WHAT RELIEF ARE YOU SEEKING?

PLEASE LIST NAMES AND ADDRESSES OF TREATING PHYSICIANS

LIST ANY WITNESSES:

FILL IN AS BELOW NAME ADDRESS TEL. DESCRIPTION OF TESTIMONY

By clicking submit, you agree to the following:

The foregoing responses are truthful and accurate to the best of my knowledge, information, and belief.
Mitigation of damages has been sufficiently explained to me by a member of the firm. I understand that, if I have been terminated, I must continue to actively seek employment in order to maximize my potential economic loss damages. I understand that I should keep a detailed chronological log of my efforts to seek employment. In addition, I understand that copies of any documents utilized in my job search (e.g. newspapers, resumes, print outs of online search, applications, fax receipts, emails, telephone records, etc.) must be preserved and may be subject to a discovery request in the future. I understand that failure to do this may result in significant loss to the value of my potential case and can result in the firm being unable to take on my case or affect the firm’s offer to me.
I am not using my employer’s computer or email system to access this form and will not communicate with the firm on such a computer or email system.
I acknowledge my responsibility to preserve and not discard any relevant evidence, including anything likely to lead to relevant evidence, including digital devices, computer records, text messages, and papers and documents.
I acknowledge that until and unless I sign a written agreement for legal services, this firm is not my attorney.