Short Intake | The López Firm

Confidential Intake Questionnaire

I. IDENTIFYING INFORMATION

Name

First Name

Last Name

FULL MAILING ADDRESS

STREET

CITY

STATE

New Jersey or New York only

ZIP CODE

TELEPHONE NOS

HOME WORK CELL

E-MAIL ADDRESS

PREFERRED METHOD OF BEING CONTACTED:

DATE OF BIRTH

YYYY

PLACE OF BIRTH

LANGUAGE

MARITAL STATUS

SEX

NATIONAL ORIGIN

RACE

DISABLED

IF SO, NATURE OF DISABILITY

MILITARY HISTORY

CRIMINAL HISTORY

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

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

II.EMPLOYMENT INFORMATION/ADVERSE PARTY

NAME OF EMPLOYER

MAILING ADDRESS OF EMPLOYER

TYPE OF BUSINESS

DESCRIBE YOUR DUTIES, JOB TITLE, & ANNUAL SALARY

DID YOU BELONG TO A UNION

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.