Client Intake Form (Page 5 of 9) in pdf

Client Intake Form - Employment Law…5 of 9

_________________________________________________________________________________

15. Do you have written documentation (e.g., cards, letters, diaries, journals, or calendars) relevant to

your complaint? If so, describe the document(s).

_________________________________________________________________________________

16. Are you aware of other employees who have experienced harassment or discrimination by the

person harassing or discriminating against you? If so, state the employee's name and the details of

his or her experiences, if known to you.

_________________________________________________________________________________

17. When/if you were discharged, did you sign a resignation letter, waiver, or release? If so, please

attach

copy

and

describe

the

circumstances

under

which

you

signed.

_________________________________________________________________________________

18. Do you believe the employer's actions violated its own procedures or policies? If so, explain.

_________________________________________________________________________________

INJURIES/DAMAGES

1. Are you currently working? ( ____ ) Yes ( ____ ) No

2. If you are not working:

What is the last date that you worked?_________________

Why did you stop working?

Medical Leave/Disability: _______________________

ii.

Termination/Forced Resignation: _________________

iii.

Other: _______________________________________

Client Intake Form Page 5