Client Intake Form (Page 7 of 9) in pdf

Client Intake Form - Employment Law…7 of 9

_____________________________________________________________________

Since the harassment/discrimination, how frequently do you think about it? How do you

feel when you remember the incident(s)?

_____________________________________________________________________

How have your family members reacted to the incident?

_____________________________________________________________________

How have your personal friends reacted to the harassment/discrimination? Describe

any effect this incident has had on your personal relationships?

_____________________________________________________________________

What are your present feelings about your dealings with your former employer?

_____________________________________________________________________

Have

you

undergone

psychiatric

psychological

treatment?

( ____ ) Yes ( ____ ) No.

If yes, identify providers below:

Name: _________________________________________________________

ii.

Address: _______________________________________________________

iii.

Telephone:______________________________________________________

iv.

Name: _________________________________________________________

Address: _______________________________________________________

Client Intake Form Page 7