Intake Form

Case Summary

You're in the right place.

We've helped thousands of California workers understand their rights, and we'd like to help you too. This form takes most people 5–10 minutes to complete, and your answers help our legal team evaluate your situation.

Everything you share is completely confidential and securely encrypted. Nothing leaves this form without your permission.

A few tips before you start:

✔ Answer as best you can. Rough dates and estimates are fine.

✔ Skip anything that doesn't apply to you.

Our team reviews every submission and will be in touch promptly.

Contact information

1. Background

Name of Employer you are contacting us about *

Employer City, State

Job title

Briefly describe your job duties

How much were you paid? (e.g, $X/year, any commission or bonuses)

2. Work Status

What best describes your employment status? *

Approximate separation date *

Use MM-DD-YYYY (e.g., 06-10-2026)

What reason did your employer give for your termination? *

Have you been offered severance? *

Yes

No

What was the amount of the severance offered?

Have you signed/accepted the severance agreement?

Yes

No

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

Were you given less than 5 days to sign?

Yes

No

3. Discrimination & Harassment

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

Briefly describe what happened

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

Yes

No

4. 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.

Tell us about the retaliation

5. Employment History

Did your Employer ever suspend or discipline you?

Yes

No

Please provide details and dates

Did you receive any written or verbal negative feedback regarding your performance?

Yes

No

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

Have you previously worked with an attorney on this matter?

Yes

No

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

Yes

No

6. Wage and Hour

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.

Did major decisions require your supervisor's approval?

Yes

No

Did you follow established procedures in doing your job assignments?

Yes

No

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

Yes

No

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)

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

Always

Sometimes

Never

Not applicable

Did you ever work off the clock or during breaks? (e.g., waiting in security lines, setting up before your shift, answering calls during lunch, etc.)

Yes

No

Did your Employer fully reimburse you for personal vehicle use/mileage?

Yes, fully reimbursed.

No, not fully reimbursed.

Closing

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

Authorization to Share Information

If Labor Law PC is unable to represent me, I authorize the firm to share a brief summary of my matter and contact information with attorneys in its referral network for evaluation purposes. I understand I am under no obligation to retain any referred attorney.

Certification and Acknowledgement

By submitting this form, you confirm that the information provided is accurate to the best of your recollection, and that no attorney-client relationship exists until a retainer agreement is signed.

Submit when ready. Our team will take it from there.