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Learn
About
Practice Areas
Contact us
☏ (973)908-8638
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Confidential Intake Questionnaire
I. IDENTIFYING INFORMATION
Name
*
First Name
Last Name
FULL MAILING ADDRESS
STREET
CITY
STATE
ZIP CODE
COUNTY
TELEPHONE NOS
HOME WORK CELL
E-MAIL ADDRESS
PREFERRED METHOD OF BEING CONTACTED:
DATE OF BIRTH
MM
DD
YYYY
PLACE
LANGUAGE
MARITAL STATUS
MARRIED
DIVORCED
SINGLE
WIDOWED
IF MARRIED, NAME OF SPOUSE
SEX
RACE
NATIONAL ORIGIN
COLOR
DISABLED
YES
NO
IF SO, NATURE OF DISABILITY
MILITARY HISTORY
YES
NO
HONORABLE DISCHARGE
CRIMINAL HISTORY
YES
NO
If yes, describe including the names of any counsel used:
PRIOR LAW SUITS
YES
NO
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
YES
NO
If yes, describe
PRIOR TERMINATIONS FROM EMPLOYERS
YES
NO
If yes, describe
II.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
NUMBER OF EMPLOYEES IN YOUR DEPARTMENT
DEPARTMENTS YOU WORKED IN
DESCRIBE YOUR DUTIES
WHAT WAS THE DATES OF SUPERVISION AND NAME, RACE, ETHNICITY, AGE, AND GENDER OF YOUR SUPERVISOR
WERE YOU EMPLOYED
PART TIME
FULL TIME
TEMP
PERMANENT
PROBATIONARY
CIVIL SERVICE
HOW DID YOU FIND THIS JOB
REQUIREMENTS FOR JOB (EDUCATION, SPECIAL TRAINING, ORIENTATION, ETC.)
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
YES
NO
IF SO, WHICH ONE
III.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
GOOD
SATISFACTORY
UNSATISFACTORY
POOR
DO YOU HAVE A COPY OF YOUR PERSONNEL FILE?
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.
Thank you!
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