Client Intake Form (Page 3 of 9) in pdf

Client Intake Form - Employment Law…3 of 9

2. Who is/was harassing you and/or discriminating against you? (Include name(s) and job title(s):

_________________________________________________________________________________

3. What happened to you to prompt this complaint? (Be specific as possible in describing the

harassment/discrimination. Include names, dates, and locations. Try to describe the "who, what,

when, where, why, and how" of the incident(s). Attach extra pages if necessary.)

_________________________________________________________________________________

4. What was your immediate reaction to the harassment/discrimination? Did you have any immediate

physical reaction? If so, describe.

_________________________________________________________________________________

5. Who was the first person you spoke to about the harassment/discrimination? What did you say?

_________________________________________________________________________________

6. Did you ever protest this treatment? To whom? When? Under what circumstances? What actions

were taken, if any?

_________________________________________________________________________________

7. What were the reasons given to you for your treatment?

_________________________________________________________________________________

8. Do you feel that the reasons given to you were false or insufficient? Why?

_________________________________________________________________________________

Client Intake Form Page 3