Client Intake Form (Page 6 of 9) in pdf

Client Intake Form - Employment Law…6 of 9

3. If you are on disability:

Who is the medical provider who placed you on leave?

Name:_________________________________________________________

Address: _______________________________________________________

iii.

Phone: _________________________________________________________

Have you been prescribed any medication(s)? If so, list each medication and the

date(s) it was prescribed.

___________________________________________________________________________

4. If no longer employed, what efforts have you made to obtain new employment? (Include the date of

application; position and salary sought; and the results of the application. Begin with your most recent

efforts.)

a._________________________________________________________________________

___________________________________________________________________________

b._________________________________________________________________________

___________________________________________________________________________

c._________________________________________________________________________

___________________________________________________________________________

5. How has this employment action affected emotional health?

_________________________________________________________________________________

__________________________________________________________________________________

In thinking about or talking about the harassment/discrimination, did you ever cry? How

often?

_____________________________________________________________________

If applicable, describe how you feel (or felt) looking for other employment. Do you

discuss your previous employment with prospective employers?

Client Intake Form Page 6