Client Intake Form

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Client Intake Form - Employment Law…1 of 9
Please print and fill out the form below. Feel free to attach additional pages if needed. For clarity, please label continuations with the appropriate
section and item numbers.
CONFIDENTIAL ATTORNEY-CLIENT COMMUNICATION
I. GENERAL INFORMATION
Client's Name: _____________________________________________________________________
Home Address:____________________________________________________________________
Telephone (Home):________________________ Telephone (Work):__________________________
Social
Security
Number:
________________________________________________________
Employer/Defendant:________________________________________________________________
How were you referred to this law firm? _________________________________________________
II. REASON FOR CONTACT
_____ Breach of Contact
_____ Non-Compete Agreement
_____ Termination of Employment (date of termination _________ )
_____ Severance Agreement (deadline to sign __________ )
_____ Failure to Promote (date of denial of promotion __________ )
_____ Denial of Benefits (e.g., wages, pension, health insurance) (date of denial ____________)
_____ Failure to Hire (date of rejection ____________ )
_____ Violation of Employer's policies and procedures (date violation occurred ___________ )
_____ Sexual Harassment
_____ Racial Harassment
_____ Discrimination (check all that apply)
Race
Sex
National Origin
Age
Disability
Religion
Sexual Orientation
Pregnancy
Illness/Injury
Marital Status
Pension or other benefit status
Retaliation
Workers' Compensation claim
Other: ___________________________________________________________________

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