Intake Form

NEW INTAKE FORM

Thank you for contacting Labor Law PC.

Please complete this form in full so we can properly evaluate your potential case.
All information you provide is strictly confidential and securely transmitted using industry-standard 128-bit SSL encryption.
If you have any questions, please contact our office.
We look forward to reviewing your submission.

Contact information:

First Name *

Last Name *

Date of birth *

Email *

Phone *

Address *

City *

State *

Postal code *

Apartment

1. Background

Name of the Employer you are seeking advice about: *

Working arrangement: *

On-site

Remote/Off-site

Hybrid (mix of both on-site and remote/off-site)

Work location: *

Job title: *

Job duties: *

Compensation amount: *

Union member? *

Yes

I don't know

2. Workforce Demographics:

Number of employees working for this employer: *

1-5

6-25

26-49

51-99

100+

Other/I don’t know

3. Work Status

When was your approximate start date with this employer?

What best describes your employment status?

Currently Employed
Fired / terminated for a reason
Laid off as part of a reduction or restructuring
Resigned
Applicant
No elements found. Consider changing the search query.
List is empty.

If not employed, what reason/s did your Employer provide for your termination?

Do you know if your position was replaced or were your job duties assumed by another employee?

Replaced

Duties assumed by another employee

Has not been filled yet

I don’t know

Not applicable

When was your approximate last day with this employer?

If you’ve been separated from your employment, have you found a new job?

Yes

Not applicable

Who is your new employer and when did you start working for them?

Did you sustain any injuries at work during your employment with this Employer?

Yes

What type of injury (physical, mental, etc.)?

When did it occur?

Did you file worker's compensation claim?

If you filed a worker's compensation claim, did you get a worker's compensation attorney?

4. Severance

Please select from the choices below if you were separated from your employment (terminated/quit):

Have you been offered severance?

Yes

What was the amount of the severance offered?

Have you signed/accepted the severance agreement?

Yes

What is the deadline for your response to the severance?

Were you given less than 5 days to sign?

How many days has it been since you signed the severance agreement?

5. Discrimination & Harassment

Do you believe you were discriminated against or harassed? If YES, select how you believe you were discriminated or harassed.

Physical Disability or Medical Condition (yourself or a family member)

Mental Disability

Pregnancy (yourself or a partner)

Race

Religion

Gender/Sex

National origin

Age

Sexual orientation/gender identity

How were you discriminated or harassed based on the above categories?

Have there been instances where you felt pressured or uncomfortable due to someone's sexual advances, comments, or behaviors at work?

Yes

Please provide details.

Please specify if any promotions, benefits, or job continuations were offered or threatened to be withheld in exchange for sexual favors (quid pro quo harassment).

6. Medical Issues

Did you or any family members experience medical issues during your employment? *

Yes

What was the medical issue?

If applicable, do you believe it might have influenced your Employer's actions to treat you differently?

Did you require any workplace accommodations due to your or a family member’s medical condition/disability needs?

Yes

Please explain your work restrictions, request for accommodations, and any issues regarding your requests.

7. Retaliation

Do you believe you were retaliated against? If yes, select the reason.

Requested or took medical, family, disability, or pregnancy leave.

Reported or complained about illegal, unethical, or unfair practices.

Reported or complained about discrimination or harassment.

Reported inaccuracies or issues with pay.

Requested a workplace accommodation (disability, medical, or religious).

Reported safety issues or poor working conditions.

Participated in or cooperated with a workplace investigation.

How did the employer retaliate against you? (e.g., termination, demotion, reduced hours)

Did you report the retaliation?

Who did you report it to? (Name or department)

When did you report it?

How did you report it? (Verbal, email, written complaint, etc.)

What happened after you reported it? (Describe any actions taken against you, changes in treatment, or further retaliation).

8. Positive Employment Events

Please tell us about all positive written performance evaluations, awards, promotions, etc.:

9. Negative Employment Events

Did your Employer ever suspend or discipline you?

Yes

Please provide details and dates

Did you receive negative written performance evaluations?

Yes

Please provide details and date

Share any information that could be considered unfavorable, even if it seems minor.

10. Wage and Hour

Please complete this section only if you are classified as a salaried/exempt employee. Otherwise, skip to "Employment Conditions and Facilities"

How were you paid for your work?

Salary

Hourly

Piece rate

Commission only

Work Supervision

I was closely supervised.

I was rarely supervised.

Supervision of other employees

I supervised two or more employees.

I did not supervise at least two employees.

Were you also paid a commission?

Yes

Were you engaged in sales?

Yes

Where did you spend most of your time working?

Fixed location (employer's premises/home office)

Not at a fixed location (e.g. in the field)

Did you on average earn half or more of your income from sales?

Did you receive any other compensation, such as bonuses/other pay?

Yes

How much is the total YEARLY amount of your other compensation?

Employment Conditions and Facilities:

What were your general working hours?

How many days per week did you work on average?

Breaks

How often did you get a 30-minute meal break if you worked more than 5 hours?

Always

Sometimes

Never

Not applicable

How often did you get at least two (2) 10-minute rest breaks when you worked between 6 and 10 hours?

Always

Sometimes

Never

Not applicable

Were you allowed to leave the premises during your meal breaks?

Yes

Not applicable

How often were you required to carry your phone/radio during breaks?

Always

Sometimes

Never

Not applicable

How often did your Employer interrupt your breaks, if any?

Always

Sometimes

Never

Not applicable

How often were you completely relieved of your job duties during your rest periods and meal breaks (e.g. you didn't have to respond to any work calls/texts during your breaks)?

Always

Sometimes

Never

Not applicable

Timekeeping

How did your Employer track your time?

Does your Employer adjust the times you clock in and out for your work or breaks?

Yes

Please explain how they do it.

Did you ever work “off the clock” (working or preparing for work before clocking-in or after clocking-out)?

Yes

What, if anything, did you have to do BEFORE you clocked in and why?

What, if anything, did you have to do AFTER you clocked out and why?

Please proceed to the next question.

Personal Equipment and Expenses

Did you have to use your personal vehicle for work other than for commuting to and from work?

Yes

Not applicable

If you selected YES, did your Employer reimburse you for personal vehicle use/mileage?

Did you have to use your personal phone for work?

Yes

If you selected YES, did your Employer reimburse you for any of your phone costs?

Were you required to pay for any other work-related expenses (e.g. uniforms, supplies)?

Yes

If you selected YES, did your Employer reimburse you for all these expenses?

Legal and Employment History

If you select YES to any of these questions, please provide details.

Have you filed a claim with the EEOC, CRD, or Labor Commissioner regarding this Employer?

Yes

If YES, please provide details(EEOC, CRD, or Labor Commissioner regarding this Employer)

Have you ever been involuntarily terminated from a previous Employer?

Yes

If YES, please provide details(involuntarily terminated from a previous Employer)

Have you ever been arrested?

Yes

If YES, please provide details(you ever been arrested)

Do you have any blogs, public websites, Facebook accounts or other social media accounts?

Yes

If so, please provide Facebook names, IG handles, websites, etc.

Do you have, or have you had, any criminal cases (felony, misdemeanor) filed against you?

Yes

Please provide details including dates, issues involved, and current or final disposition.

Have you ever filed for bankruptcy?

Yes

When was it filed?

Has it been discharged?

Have you ever been accused by any Employer of dishonesty, such as theft or lying?

Yes

If YES, please provide details(you ever been accused by any Employer of dishonesty, such as theft or lying)

Have you previously hired or been terminated by another attorney for this matter?

Yes

If YES, please provide details(previously hired or been terminated by another attorney for this matter with this Employer)

How did you hear about our law firm?

Internet Search

Social Media (Facebook, X, LinkedIn)

Referral from another lawyer or professional

Referral from a friend or family member

Google Reviews

Yelp

Other

Please specify.

Please share any other important details you haven't mentioned yet.

11. Certification and Acknowledgement

By submitting this intake form, you certify and acknowledge:

The information submitted in this form is confidential and privileged. We have not yet, however, agreed to potentially represent you. There will only be an attorney-client relationship once you have signed a retainer agreement which our firm may provide to you in writing; and the foregoing information which you provided is honest and accurate to the best of your recollection.

If Labor Law PC determines that we are unable to represent you, and your matter is appropriate for referral, you authorize our firm to share a limited summary of your matter and your contact information with one or more trusted attorneys within our professional referral network for the sole purpose of evaluating potential representation.

We will only share information necessary for evaluation, and only with attorneys we believe are suitable based on your claim type and jurisdiction. These attorneys are independent from Labor Law PC, and you are under no obligation to retain any referred attorney.

By providing this authorization, you consent to being contacted directly by a referral attorney regarding your matter.

Please note: Intake forms are reviewed within 1–2 business days during office hours.

Consent to Share Info *

I consent to Labor Law PC sharing my information with attorneys in Labor Law PC’s trusted referral network if my case falls outside the firm’s criteria.

Thank You

When you are finished, please click the "Submit" button.